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COMPEND OF DIAGNOSIS 



PATHOLOGICAL ANATOMY 



WITH DIRECTIONS FOR MAKING POST-MORTEM 
EXAMINATIONS 

BY s 

DR. JOHANNES ORTH 

\ i 

FIRST ASSISTANT IN ANATOMY AT THE PATHOLOGICAL INSTITUTE IN BERLIN 
TRANSLATED BY 

FREDERICK CHEEVER SHATTUCK, M.D. 

AND 

GEORGE KRANS SABINE, M.D. 

REVISED BY 

REGINALD HEBER FITZ, M.D. 

Assistant Professor of Pathological Anatomy in Harvard University 
WITH NUMEROUS ADDITIONS FROM MS. PREPARED BY THE AUTHOR 



/ o 

Sole &utf)orf?etr Enfllfsrif) HUftfon 



NEW YORK 

PUBLISHED BY HURD AND HOUGHTON 

BOSTON: H. 0. HOUGHTON AND COMPANY 

GTambribge: ®l)e fltocrsibc Press 

1878 







Copyright, 1877, 
By REGINALD H. FITZ, M. D 



RIVERSIDE, CAMBRIDGE: 
STEREOTYPED AND PRINTED BY 
H. 0. HOUGHTON AND COMPANY. 



RESPECTFULLY AND GRATEFULLY DEDICATED 



TO MY TEACHERS 



EDUARD RINDFLEISCH 



RUDOLF VIRCHOW. 



AUTHOR'S PREFACE. 



The present volume is the result of a practical want 
which has long been felt, particularly in Berlin, the seat of 
the central commission for the examination of practitioners 
of medicine and medical officials. This has become more 
evident of late, since the establishment of a separate exam- 
ination in Pathological Anatomy, the great increase in the 
theoretical and practical requirements of the civil examina- 
tion, and the promulgation of the new Regulations for the 
performance of autopsies for medico-legal purposes by foren- 
sic physicians. Although the existing works on Patholog- 
ical Anatomy are excellent, their scope includes too little 
of the practical details of the subject, and there is actually 
no book which contains comprehensive directions for mak- 
ing post-mortem examinations, for recognizing pathological 
changes in the fresh organs, and for establishing the diag- 
nosis. 

It is, of course, very evident that such absolutely practical 
knowledge can only be fully obtained from actual experience 
in performing autopsies ; but in order to make this experi- 
ence the more profitable it is necessary that a theoretical 
knowledge should first be acquired, not only of the course 
and method of the examination, but also of the alterations 
which may take place in the several parts, and of their char- 
acteristic peculiarities. This is all the more necessary as but 



vi AUTHORS PREFACE. 

few students or physicians are able to secure special oppor- 
tunities for practical training. It has been my aim to give 
such preliminary information for practical purposes, and it 
is my desire that the book may be judged from this stand- 
point. 

Having been engaged for several years in giving instruc- 
tion in both these directions, I have acquired a certain degree 
of experience in those particulars which present the greatest 
difficulty to students and physicians, and in those mistakes 
which are most commonly met with. I have therefore en- 
deavored to make the former as clear as possible, and to 
guard against the latter. It may result that certain appa- 
rently trivial matters are more comprehensively and diffusely 
treated of than others which are of greater importance ; 
should this prove to be the case, my excuse is that the main 
object has been to supply practical needs. 

In the arrangement of the contents, and in the directions 
for the performance of the autopsy, the new Prussian Regu- 
lations for forensic physicians have been closely adhered to, 
which prescribe exactly the same method which has long 
been employed in the Pathological Institute at Berlin. In 
the sections treating of diagnosis, both gross and microscopic 
appearances have been described, tbe latter only so far as 
they may be verified by an examination of fresh specimens, 
without entering into details requiring prolonged methods 
of preparation. Those who desire such information will find 
the necessary directions in the respective text-books. 

There is unfortunately at the present day a general ten- 
dency in the scientific world, for fellow-workers in the cause 
of science, to suspect the worst motives if their names are 
not mentioned. I have no wish to detract from their labors, 
and desire to state that the names of authors have been in- 



AUTHOR'S PREFACE. vii 

serted in but few instances, for the sole purpose of diminish- 
ing the size of the volume and to carry out its practical aim, 
and that I have no intention of claiming all the various state- 
ments herein made as original observations or explanations. 
I need not say that I have made use of the text-books treat- 
ing of this subject, especially the more recent ones, of Vir- 
chow, Rindfleisch, Klebs, Rokitansky, Forster, and others. 

J. ORTH. 

Berlin, May 1, 1876. 



REVISER'S PREFACE. 



The want of a suitable practical manual of Pathological 
Anatomy has been strongly felt in this country as well as in 
Germany. Some years ago, however, an important work 
was prepared by Dr. Francis Delafield, of New York, which 
has proved of great service in filling this gap. 

Since then, certain familiar appearances have received a 
new interpretation, attention has been called to recently 
discovered affections, decided improvements in method have 
been made, and numerous technical terms have been em- 
ployed which are not sufficiently explained in the usual text- 
books. A work, therefore, giving information of this sort, 
and which may also be regarded as representing Virchow's 
teaching, has a strong claim for consideration, and those 
who are acquainted with the sayings of the Professor can 
best judge of the value of his assistant's presentation of 
them. 

Dr. Orth, as is well known, has taken a prominent part 
in recent investigations, and his opportunities for practical 
work are probably unsurpassed. The reception which his 
book has met with abroad may be inferred from the fact 
that a Russian translation has been undertaken, and will 
soon appear, if it has not already been issued. 

By special arrangement with the author, the English trans- 
lation is enriched with numerous additions, which he has 



X REVISERS PREFACE. 

prepared for a subsequent edition of the original work, many 
of them representing the results of the most recent re- 
searches. The translators have fully realized the impor- 
tance of their labor, which they have undertaken with great 
earnestness, and have conscientiously performed. Whatever 
may have been sacrificed in style, has been for the sake 
of expressing the author's views as exactly and concisely as 
possible. A correct translation has been deemed of greater 
importance than an elegant one. 

Two plates have been added, the drawings for which were 
made by Dr. H. P. Quincy, and are modified from those 
contained in Virchow's " Sections-Technik," lately pub- 
lished. They illustrate the method of opening the heart, 
and the anatomical points which require consideration in 
the removal of the sternum. They are sufficiently explained 
in the text. 

To Dr. D. F. Lincoln hearty thanks are offered for his 
kindness, patience, and promptness in assisting in the cor- 
rection of the proof-sheets. 

Boston, October 20, 1877. 



TABLE OF CONTESTS, 

SERVING ALSO AS A BRIEF RECAPITULATION OF THE PROGRESS OF AN AUTOPSY. 



PAGB 

Introduction 1 

Preliminaries . 2 

Instruments . 3 

Appliances for Chemical and Microscopical Examination . . 4 



EXAMINATION OF THE BODY. 



A. INSPECTION". 

1. Inspection of the Body as a Whole .... 9 

a. General Attributes of the Body 9 

(Frame; General Nutrition; General Condition of the Skin.) 

b. Signs of Death and Decomposition . . . . . 11 

(Post-Mortem Discoloration and Rigidity.) 

2. Inspection of the Several Parts of the Body . . 13 

(Foreign Bodies ; Injuries.) 

a. Modifications of Size and Form 13 

((Edema.) 

b. Modifications of Color . . . . . . .13 

(Bronzed Skin; Icterus.) 

3. Inspection of New-born Children .... 14 

4. Morbid Condition of the Skin and Subcutaneous 

Cellular Tissuk 16 

a. General Morbid Conditions . . . . . . .16 

1. The Epidermis 16 

(Desquamation; Vesicles; Pustules.) 

2. The Cutis 17 

(Desiccation; Papules.) 

b. Special Morbid Conditions 17 



Xli TABLE OF CONTENTS. 

PAGB 

1. Hcemorrhage 17 

(Petechia; Vibices; Ecchymoses.) 

2. Inflammation ........ 18 

a. Circumscribed 18 

(Psoriasis; Miliaria; Sudamina; Herpes; Ec- 
zema ; Pemphigus ; Variola; Impetigo; Em- 
bolic Abscesses; Lichen; Prurigo; Papular 
Syphilide.) 

b. Diffuse 19 

(Erysipelas; Phlegmonous Erysipelas; Cellulitis.) 

3. Necrosis 20 

(Moist Gangrene; Noma; Dry Gangrene; Mummi- 
fication; Senile Gangrene; White Gangrene; Hos- 
pital Gangrene.) 

4. Ulcers 22 

(Superficial; Sinuous; Fistulous; Indolent; Fungous; 
Indurated ; Suppurating ; Phagedenic ; Chronic Ul- 
cer of the Leg.) 

5. Cicatrices 23 

6. Diseases of the Epithelial Appendages of the Skin . 24 

a. The Hair 24 

(Alopecia; Alopecia Areata ; Furuncle.) 

b. The Nails 24 

(Paronychia ; Onychogryphosis. ) 

c. Glands 24 

(Acne ; Acne Rosacea.) 

7. Morbid Growths in the Skin 25 

a. Hypertrophy ........ 25 

(Callus; Corn; Ichthyosis; Horny Excrescences; 
Hard Warts; Pointed Condylomata or Vege- 
tations; Elephantiasis Arabum ; Pachydermia 
Lymphangiectatica ; Sclerema Neonatorum; 
Scleroderma ; Soft Warts or Moles.) 

b. Tumors ........ 27 

1. Cystic Tumors 27 

(Comedo; Milium; Wen; Dermoid Cysts; 
Hygroma; Ganglion.) 

2. Angiomata ....... 28 

(Telangiectasis ; Cavernous Tumor.) 

3. Lipomata ........ 29 

(Lipoma Pendulum, Durum, Telangiectodes; 
Lipoma Myxomatodes ; Myxoma Lipoma- 
todes.) 



TABLE OF CONTENTS. xiii 

PAGE 

4. Myxoma 30 

5. Enchondroma 30 

(Osteoma.) 

6. Granulomata 30 

a. Lupus 30 

(Lupus Nodosus, Maculosus, Hypertro- 
phicus, Exfoliativus, Exulcerans ; Lu- 
pus Erythematodes. 

b. Lepra, Leprosy 31 

c. Syphilis . . . . . . 32 

(Hard Chancre; Mucous Patch; Lupus 
Syphiliticus.) 

d. Glanders or Farcy 33 

7. Fibroma . 33 

(Fibroma Durum, Molluscum; Keloid.) 

8. Sarcoma 33 

(Melano-sarcoma ; Sarcoma Telangiectodes, 
Haemorrhagicum . ) 

9. Carcinoma 35 

(Cancer en Cuirasse.) 
10. Epithelioma, Cancroid 36 

a. Infiltrating 36 

(Rodent Ulcer.) 

b. Papillary or Warty 38 

(Cauliflower Excrescence.) 

8. Parasitic Affections . 38 

a. Pityriasis Versicolor . . . . . .38 

b. Favus 39 

c. Herpes Tonsurans 39 

(Sycosis Parasitica; Onchomycosis.) 

9. Congenital Malformation 40 

(Fissure; Atresia.) 



B. INTERNAL EXAMINATION. 

I. THE SPINAL CANAL . . . . 41 

A. Soft Parts and Bones 41 

(Spina Bifida.) 

B. Spinal Cord and its Membrane 43 

a. General Appearance 43 

(Modification in Color.) 

b. Special Morbid Conditions 43 



xiv TABLE OF CONTENTS. 

PAGB 

1. Spinal Dura Mater 43 

2. Spinal Pia Mater ........ 44 

3. Spinal Cord 44 

(Gray Degeneration; Locomotor Ataxia; Insular Scle- 
rosis ; Descending Degeneration ; Hydromeningo- 
cele; Hydromyelocele.) 

II. CRANIUM 46 

(Scalp; Pericranium.) 

1. Periosteum 46 

( Ceph alh aem atom a . ) 

2. The Bone from Without . 47 

a. General Appearance and Character 47 

1. Size 47 

2. Shape 47 

(Mesocephalia ; Brachycephalia ; Dolichocephalia ; 
Plagiocephalia.) 

3. Color 48 

4. Consistency ........ 48 

(Craniotabes; Sutures; Wormian Bones; Fontanel 
Bones.) 

b. Special Morbid Conditions 48 

(Atrophy; New Formation of Bone.) 

3. The Bone from Within 51 

a. The Sawn Edge 41 

(Amount of Blood in the Diploe.) 

b. The Inner Surface . 51 

(Configuration ; Color.) 

4. Dura Mater of the Convexity from Without . . 52 

a. The Membrane 52 

(Thickness; Translucency; Tension; Color; Extrame- 
ningeal Haemorrhage ; Pachymeningitis Externa Ossifi- 
cans, Purulenta, Gummosa, Tuberculosa ; New For- 
mations.) 

b. Longitudinal Sinus 53 

(Thrombosis.) 

5. Dura Mater of the Convexity from Within .. . 54 

a. General Appearance and Character 54 

(Color; Haemorrhage; Haematoma.) 

b. Special Morbid Conditions 55 

1. Inflammation ,56 

(Pachymeningitis Interna Purulenta, Ossificans, Fi- 



TABLE OF CONTENTS. xv 

PAGB 

brinosa, Hemorrhagica, Pigmentosa, Adhesiva, 
Tuberculosa, Gummosa.) 

2. Neoplasms 57 

(Sarcoma; Fungus Dure Matris ; Carcinoma; Endo- 
thelioma.) 

6. Pia Mater of the Convexity 57 

a. General Appearance and Character ..... 58 

(Size [CEdema] ; Color; Amount of Blood.) 

b. Special Morbid Conditions . . . . . . .58 

1. Haemorrhage ........ 58 

(Intermeningeal, Arachnoidal Hemorrhage.) 

2. Inflammation . . . . . . . .59 

(Arachnitis Chronica; CEdema Cysticum; Pacchi- 
onian Bodies ; Meningo-encephalitis ; Arachnitis 
Fibrino-purulenta, Tuberculosa.) 

3. Parasites 60 

(Cysticercus.) 

4. Tumors 61 

7. Removal of the Brain from the Skull . . . 61 

8. Pia Mater at the Base 62 

a. Changes in the Great Vessels 62 

(Fatty Degeneration and Chronic Inflammation of the 
Intima ; Aneurism; Embolism.) 

b. Changes in the Pia 63 

(Arachnitis Tuberculosa, Fibrino-purulenta.) 

9. Surface of the Brain 64 

(Form of the Surface ; Adhesion with the Pia [Meningo- 
encephalitis Chronica] ; Color; Amount of Blood; Hemor- 
rhage ; Yellow Patches; Tubercles; Gummata; Sarcoma; 
Cysticercus.) 

10. Interior of the Brain *67 

a. The Cerebral Ventricles 67 

1. Dilatation 68 

(Hydrocephalus.) 

2. Ependyma 68 

(Ependymitis Chronica, Prolifera, Adhesiva; Hy- 
drocele Cornu Posterioris.) 

b. Section of The Cerebrum 70 

1. The Hemispheres ....... 70 

(Moisture; Puncta Vasculosa; Relative Proportions.) 

2. The Great Ganglia 71 

c. Fourth Ventricle 72 

d. Cerebellum 73 



XVI TABLE OF CONTENTS. 



PAGE 



e. Pons and Medulla Oblongata 73 

(Nerves at the Base.) 

/. Other Methods of Examining the Brain 74 

g. Morbid Conditions of the Brain 76 

1. Haemorrhage 76 

(Diffuse; Punctiform.) 

2. Softening . 76 

(Red and Yellow Softening; Apoplectic Cysts and 
Cicatrices ; Porous Softening ; Encephalitis Neona- 
torum; White Softening.) 

3. Inflammation 78 

(Encephalitis Hemorrhagica ; Yellow (Edema ; En- 
cephalitis Apostematosa, Chronica, Corticalis.) 

4. Tumors ......... 80 

(Sarcoma; Glioma; Carcinoma; Psammoma; Cho- 
lesteatoma; Melanoma; Osteoma, etc.) 

5. Parasites 81 

(Cysticercus ; Echinococcus.) 

11. Dura Mater and Bone at the Base .... 82 

(Pachymeningitis Suppurativa; Thrombophlebitis; Pituitary 
Body.) 

12. Face . 82 

a. Parotid Gland 82 

(Parotitis Apostematosa ; Enchondroma ; Myxochondro- 
ma; Cystosarcoma.) 

b. Bones of the Face 83 

(Cancer; Fibroma; Cysts; Sarcoma; Epulis; Periostitis; 
Necrosis; Parulis.) 

13. Nasal Cavity 84 

(Glanders; Syphilis; Polypi; Diphtheritis, etc.) 
14*. Eye 85 

a. Retina 85 

(Haemorrhage; Retinitis.) 

b. Choroid 85 

(Tubercle; Metastatic Inflammation.) 

c. Optic Nerve 86 

(Gray Atrophy.) 

15. Inner Ear 86 

(Caries; Cholesteatoma.) 



TABLE OF CONTENTS. xvii 

PAGE 
III. THORACIC AND ABDOMINAL CAVITIES . .87 

(Opening ; Air in Abdominal Cavity ; Arteritis Umbilicalis ; 
Thrombophlebitis Umbilicalis.) 

1. Soft Parts 89 

a. Panniculus Adiposus 89 

(Thickness; Color; [Atrophy.]) 

b. Muscles of Neck, Chest, and Abdomen .... 89 

1. General Characteristics 89 

(Size ; Color; Consistency.) 

2. Special Morbid Conditions . . . . . . 90 

a. Haemorrhage 90 

(Hsematoma Recti Abdominis.) 

b. Parenchymatous Inflammation .... 90 

(Granular Opacity; Hyaline Degeneration ; Fatty 
Degeneration.) 

c. Interstitial Inflammation 91 

(Suppurative, Chronic Fibrous Myositis.) 

d. Tumors 91 

e. Parasites 91 

(Trichinae.) 

c. Mammary Gland 93 

a. General Appearance 93 

(Effects of Age; Functional Activity, etc.) 

b. Special Morbid Conditions ..... 94 

1. Suppurative Inflammation .... 94 

2. Chronic Inflammation ..... 94 

(Cystic Dilatation of Milk Ducts.) 

3. Tumors 94 

a. Carcinoma 94 

(Cancroid.) 

b. Sarcoma . .... . . 95 

(Cystosarcoma Proliferum; Myxosarco- 
ma.) 

c. Fibroma . . . . . . 96 

d. Lipoma 96 

(Axillary Lymphatic Glands.) 

2. Inspection of the Abdominal Cavity .... 96 

a. Position of the Organs 97 

(Hernia; Volvulus; Invagination; Transposition.) 

b. Color and Quantity of Blood . . . . . . 99 

c. Abnormal Contents 100 

1. Transudation . 100 

b 



XVlil TABLE OF CONTENTS. 

PAGE 

2. Pus 101 

3. Blood 101 

4. Portions of Food . . . . . . . .101 

5. Loose Bodies . 102 

(A.) Thorax . . . . 103 

1. Inspection of the Thorax .103 

a. General Appearance 103 

(Pigeon-breast.) 

b. Bones . . . . 103 

1. Sternum 103 

2. Ribs ..'.... . . .103 

2. Method of Opening the Thorax . . . . . 104 

3. Inner Surface of the Bones 105 

a. Sternum 105 

(Caries; Erosion; Changes in the Marrow.) 

o. Ribs 105 

(Rosary of Rickets; Caries ; Effects of Age.) 

c. Sterno-clavicular Articulation and Clavicle . . . 106 

4. Inspection of the Thoracic Cavity 107 

a. Condition of the Exposed Lung , . . . , 107 

(Distention; Color.) 

b. Pleural Cavity 107 

(Abnormal Contents.) 

5. Mediastinum 107 

a. Connective Tissue 107 

(Emphysema; Haemorrhage ; Suppurative and Fibrous 
Inflammation.) 

b. Mediastinal Lymphatic Glands 108 

(Caseation; Tuberculosis.) 

c. Thymus Gland .108 

(Persistence ; Haemorrhage ; Abscess ; Lymphosarcoma 
Thymicum.) 

6. Pericardium 108 

(Method of Opening.) 

a. Contents 109 

b. Morbid Conditions 109 

1. Inflammation 109 

(Pericarditis Fibrinosa; CorVillosum; Suppurative, 
Chronic Fibrous, and Adhesive Pericarditis ; Syne- 
chia Pericardii.) 

2. Tubercles 110 



TABLE OF CONTENTS. xix 

PAGE 

3. Metastatic Tumors . Ill 

c. Subpericardial Fatty Tissue . . . . . . Ill 

(Mucous Atrophy; Lipoma; Ecchymoses.) 

Heart Ill 

a. External Examination Ill 

1. Position . . . Ill 

2. Size 112 

3. Form 112 

4. Color 112 

5. Consistency . 112 

6. Coronary Vessels 112 

7. Distention of Individual Portions 113 

b. Opening the Heart in Situ . . . . . . . 113 

c Blood 114 

1. Coagulation ......... 114 

2. Color 115 

3. Changes in Composition . . . . . . 116 

(Hydremia; Leucocytosis ; Leucsemia.) 

4. Morphological Admixtures 117 

a. Cells 117 

b. Pigment 117 

c. Fat 118 

d. Organisms . . . . . . . .118 

(Spirilla; Bacteria; Micrococci.) 

e. Bubbles 120 

(Gas; Air.) 

d. Removal and Complete Opening of the Heart . . .120 

(Method of Testing Valves.) 

e. Interior of the Heart 121 

1. General Appearances 121 

(Size of the Ventricles; Thickness of the Walls; 
Weight of the Heart; Color and Consistency of the 
Muscular Substance.) 

2. Special Morbid Conditions 122 

a. Muscular Tissue 122 

a. Atrophy 122 

(Brown Atrophy; Obesity of the Heart; 
Fatty Degeneration; Rupture.) 

b. Hypertrophy 125 

(Secondary and Idiopathic.) 

c. Inflammation 125 

1. Parenchymatous . . . . .126 

2. Interstitial 126 



XX TABLE OF CONTENTS. 

PAGE 

(Myocarditis Aposternatosa, Chronica 
Fibrosa ; Chronic Aneurism of the 
Heart.) 

d. Tumors 127 

(Gumma; Tubercle; Sarcoma; Myxosar- 
coma; Myoma; Carcinoma; Melanoma.) 

e. Entozoa 127 

(Cysticercus; Echinococcus.) 
/. Congenital Malformation . . . .127 

(Patency of the Foramen Ovale, and Ven- 
tricular Septum.) 

6. Endocardium 127 

(Subendocardial Fat ; Haemorrhage.) 
a. Parietal Endocardium . . . . .128 
(Endocarditis Chronica Fibrosa, Verrucosa, 
Ulcerosa; Acute Aneurism of the Heart.) 
o. Valvular Endocardium . . . . 128 

(Endocarditis Valvularis, Basilaris, Chron- 
ica Fibrosa, Eetrahens, Chordalis, Ver- 
rucosa, Petrifica, Recurrens, Ulcerosa, 
Maligna ; Acute Valvular Aneurism ; 
Chronic Valvular Aneurism; Haematoma; 
Fenestration; Valvular Thrombosis.) 

7. Commencement of the Aorta and Coronary Arteries 132 

(Coronary Arteries ; Fatty Degeneration of the 
Intima ; Endarteritis Chronica ; Hypoplasia 
of the Aorta; Abnormal Origin of Coro- 
nary Arteries.) 
8. Removal of the Lungs 132 

a. Pulmonary Pleura 133 

(Inflammation; Tubercles; Cancerous Nodules; Local 
Necrosis; Lymphangitis.) 

b. External Examination of the Individual Lobes . . . 135 

1. Size .135 

2. Form 135 

(Emphysema ; Contraction.) 

3. Color 135 

(Slaty ; Brown, etc.) 

4. Distention with Air and Consistency . . . . 136 

(Alveolar and Interstitial Emphysema.) 

c. Internal Examination . . . . . . . .137 

1. General Condition and Appearance . . . . 138 
(Quantity of Blood ; Color ; [ Anthracosis ;] Slaty and 
Brown Induration.) 



TABLE OF CONTENTS. xxi 

PAGE 

2. Special Morbid Conditions 139 

a. Parenchyma and Smallest Bronchi . . . 139 

a. Vesicular Emphysema 139 

b. Atelectasis 140 

(Foetal, From Compression, From Plug- 
ging, Marantic ; Hypostasis ; Spleniza- 
tion ; Gelatinous Pneumonia.) 

c. (Edema 141 

(Collateral (Edema.) 

d. Haemorrhage . . . . . . 141 

(Hemorrhagic Infarction ; Circumscribed 
Gangrene; Embolic Infarction.) 

e. Inflammation ....... 144 

1. Fibrinous . . . . . . 144 

(Red, Yellow, and Gray Hepatization; 
Diffuse Gangrene; Pleuro-pneumonia; 
Fibrinous Bronchitis; Carnification.) 

2. Catarrhal 146 

(Broncho-pneumonia; Chronic Catar- 
rhal Pneumonia; Pneumonia from In- 
halation of Foreign Bodies; Diffuse 
Gangrene ; Pneumonia in Childhood ; 
White Hepatization.) 

3. Cheesy . . . . . . . 148 

(Desquamative Pneumonia ; Miliary 
Cheesy Pneumonia; Acute Phthisis.) 

4. Metastatic 149 

5. Interstitial . . . . . . 150 

(Pneumonia Apostematosa ; Lymphan- 
gitis Pulmonalis Apostematosa; 
Chronic Interstitial Pneumonia or 
Cirrhosis; Slaty Induration.) 

6. Peribronchitis 151 

(Peribronchitis Purulenta, Chronica Fi- 
brosa, Caseosa.) 

7. Bronchitis 151 

(Bronchitis Chronica Fibrosa; Caseosa.) 

/. Tubercles 152 

1. Disseminated 152 

2. Localized 152 

(Tuberculous Inflammation.) 

3. Tuberculous Bronchitis . . . 153 
g. Formation of Cavities 154 



xxii TABLE OF CONTENTS. 

PAGE 

1. Bronchiectasis .... 154 

(Putrid Bronchitis.) 

2. Cavities; Vomicae 154 

Pulmonary Phthisis . . . . 156 

(Pulmonary Calculi; Gangrenous Phthi- 
sis.) 

h. Tumors . 157 

(Phthisis Carcinomatosa; Lymphangitis Car- 
cinomatosa, etc.) 

i. Parasites 158 

(Echinococcus.) 

)8. Larger Bronchi 158 

(Bronchitis Catarrhalis Acuta et Chronica, Pu- 
rulenta, Capillaris; Tumors.) 

y. Pulmonary Vessels 159 

(Embolism; Fat Embolism.) 

8. Bronchial Glands 161 

(Pigmentation; Inflammation; Tuberculosis; Cal- 
cification; Sarcoma; Carcinoma.) 

9. Costal Pleura and Posterior Portions of the Ribs 161 

(Tubercles; Lipoma; Pleuritic Ossification; Lymphatic 
Glands.) 

10. Cervical Organs . 162 

a. Method of Removal 162 

b. The Individual Parts or Organs 164 

1. Great Vessels and Nerves 164 

a. Vessels 164 

(Endarteritis; Calcification; Embolism.) 

b. Nerves ........ 164 

(Sympathetic ; Pneumogastric.) 

2. Mouth and Pharynx 165 

(Color; CEdema; Stenosis; Wounds of the Tongue; 
Catarrhal, Fibrinous, Diphtheritic, Phlegmonous, 
Inflammation ; Syphilis ; Tuberculosis ; Lupus ; 
Lepra; Cysts; Macroglossia ; Carcinoma; Thrush.) 

3. (Esophagus 170 

a. General Morbid Conditions 170 

(Dilatation; Diverticula; Stenosis; Color.) 

b. Special Morbid Conditions 171 

(Inflammation; Injury; Carcinoma; Thrush.) 

4. Larynx and Trachea 172 

((Edema; Fibrinous, Diphtheritic, Phlegmonous, and 
Chronic Catarrhal Inflammation; Syphilitic; Tu- 



TABLE OF CONTENTS. xxiii 



PAGE 



bercular and Typhoid Ulceration; Tracheal and 
Arytenoid Perichrondritis ; Tubercles ; Polypi ; 
Cysts ; Carcinoma.) 

5. Submaxillary Glands 177 

(Adenitis and Periadenitis Apostematosa.) 

6. Thyroid Gland 178 

(Sarcomatous, Carcinomatous, Parenchymatous, Gel- 
atinous, Cystic, Hemorrhagic, Fibrous, Osseous, 
Aneurismal, Varicose, Amyloid Bronchocele; Ac- 
cessory Bronchocele.) 

7. Cervical Lymphatic Glands . . . . . 179 

11. The Deep Muscles of the Neck and the Cervical 

Vertebrae . . . 180 

(Caries; Retropharyngeal Abscess.) 

12. Hydrostatic Test in New-born Children . . 180 

(B.) Abdomen . . . 181 

1. Peritoneum of the Anterior Abdominal Wall . .182 

(Peritonitis Fibrino-purulenta, Adhaesiva, Haemorrhagica ; 
Hematoma Peritonei ; Peritonitis Ulcerosa; Tuberculosis; 
Tumors.) 

2. Omentum 183 

(Atrophy; Omentitis; Tumors; Echinococcus.) 

3. Spleen 186 

(Accessory Spleen.) 

a. External Examination 186 

1. General Appearance 186 

a. Position 186 

b. Size 187 

c. Form 188 

d. Color 188 

e. Consistency . . . . . . . .188 

2. Capsule of the Spleen 189 

(Perisplenitis; Rupture.) 

b. Internal Examination . . . . . . . .189 

1. General Appearance . . . . . . . 189 

(Quantity of Blood; Color; Follicles; Trabecule ; 
Pulp; Enlargement; Atrophy.) 

2. Special Morbid Conditions . 102 

a. Amyloid Degeneration . . . . . 192 

(Sago-spleen ; Lardaceous or Waxy Spleen.) 

b. Inflammation 193 



XXIV TABLE OF CONTENTS. 

PAGB 

(Intermittent Fever ; Leucaemia; Metastatic In- 
flammation.) 
e. Hemorrhagic Infarction. . . . . .194 

d. Syphilis and Tuberculosis . . . . . 195 

e. Tumors .196 

(Malignant Lymphosarcoma, etc.) 

/. Parasites 196 

(Echinococcus.) 

g. Changes in the Vessels 197 

(Aneurism; Thrombosis; Phlebolites.) 
4. Kidneys and Supra-renal Capsules . . . . 197 
(Method of Examination; Malposition; Floating Kidney; 
Horse-shoe Kidney.) 

a. Supra-renal Capsules . . . . . . . .198 

(Amyloid Degeneration ; Inflammation ; Struma ; Glioma 
Suprarenali; Cheesy Degeneration; Gummata; Car- 
cinoma; Addison's Disease.) 

b. Kidneys 200 

(Main Incision.) 

1. Capsules of the Kidney 201 

(Fibrous and Suppurative Perinephritis.) 

2. Outer Surface of the Kidney 201 

a. General Characteristics 201 

1. Size 201 

2. Form .202 

3. Color 203 

4. Consistency 203 

b. Special Morbid Conditions 203 

(Hemorrhagic Infarction; Abscess; Tubercle; 
Cysts; Hydrops Renum Cysticus, etc.) 

3. Surface of the Section of the Kidney .... 205 

a. General Characteristics ..... 205 

(Relative Proportion of Cortical and Medullary 
Portion ; Quantity of Blood; Color.) 

b. Special Morbid Conditions 207 

1. Haemorrhage ...... 207 

(Hemorrhagic Infarction.) 

2. Amyloid Degeneration ..... 208 

3. Thrombosis of the Veins .... 209 

4. Inflammation ....... 209 

a. Parenchymatous ..... 209 

b. Interstitial 211 

(Fibrous, Cysts ; Purulent ; Metastatic ; 



TABLE OF CONTENTS. XXV 

PAGE 

Phthisis Renalis Apostematosa; Py- 
elonephritis ; Nephritis Papillaris 
Diphtheritica.) 

c. Catarrhal 215 

Hyaline Casts . . . . . .216 

5. Phenol Infarction 216 

a. Lime Infarction 216 

b. Uric Acid Infarction . . . . 217 

c. Hcematoidine Infarction . . . .217 

d. Bilirubine Infarction . . . . 217 

e. Nephritis Urica . . . . .218 

6. Tuberculosis 219 

(Disseminated ; Phthisis Renalis Tubercu- 
losa.) 

7. Gummata 220 

8. Tumors 220 

(Adenoma; Carcinoma; Sarcoma.) 

4. Calices, Pelvis, and Ureters 220 

((Edema; Hsemorrhages; Purulent and Diphtheritic 
Inflammation; Tuberculosis; Concretions; Cysts; 
Hydronephrosis; Congenital Duplication.) 
5. Pelvic Viscera ......... 223 

a. Contents of the Bladder . . . ... . .224 

(Quantity; Color; Pus; Hyaline Casts ; Crystalline Sedi- 
ment.) 

b. General Method of Removal 225 

c. Bladder and Urethra . . . . . . . .227 

1. Bladder 227 

a. General Morbid Conditions 227 

(Distention ; Trabecular Hypertrophy ; Diver- 
ticula; Shape; Color; Consistency.) 

b. Special Morbid Conditions 228 

(Haemorrhage ; Inflammation (Catarrhal, Pu- 
rulent, Diphtheritic) ; Tuberculosis ; Carci- 
noma ( Vesico-vaginal Fistula); Villous Can- 
cer; Laceration; Pericystitis Gangrenosa.) 

2. Urethra 230 

(Stricture ; False Passages.) 

d. Prostate 231 

(Calculi; Purulent Inflammation; Tuberculosis; Hyper- 
trophy; [Adenoma; Fibromyoma;] Carcinoma; Sar- 
coma.) 

e. Vesiculoz Seminales and Vasa Deferentia . . . .232 



xxvi TABLE OF CONTENTS. 

PAGE 

(Inflammation; Tuberculosis.) 
/. Testis, Epididymis, and Spermatic Cord .... 233 
(Position; Monorchis; Cryptorchis.) 

1. Spermatic Cord and Tunica Vaginalis Propria . . 234 

(Varicocele ; Hydrocele Congenita, Funiculi Sper- 
matid, Cystica, Herniosa, Tunicae Vaginalis Pro- 
prise ; Hematocele ; Spermatocele ; Periorchitis 
Fibrosa, Prolifera, Adhaesiva, Suppurativa.) 

2. Exterior of the Testis and Epididymis . . . 235 

(Size; Consistency.) 

3. Interior of the Testis and Epididymis . . . .236 

(Haemorrhage; Inflammation; Tuberculosis; Syphi- 
lis; [Orchitis Interstitialis Fibrosa; Sarcocele 
Syphilitica;] Myxosarcoma; Chondrosarcoma; 
Chondrocarcinoma. ) 

g. Vulva 240 

((Edema; Elephantiasis; Lacerations; Haematoma Vul- 
vae; Purulent and Diphtheritic Inflammation; Gangrene; 
Puerperal Ulcers; Condylomata; Chancre; Carcinoma; 
Melanoma.) 
h. Vagina .......... 241 

1. General Appearances . . . . . . 242 

(Position; [Cystocele, Rectocele, Enterocele Vagi- 
nalis;] Size; Shape; Color.) 

2. Special Morbid Conditions 243 

(Inflammation; Lacerations; Necrosis; Fistulse ; 
Diphtheritis ; Syphilis ; Tuberculosis ; Carcinoma ; 
Formation of Cloacae.) 
i. Uterus 246 

1. External Examination ...... 246 

(Size; Shape [Elongation]; Changes in Position; 
[Ante-, Retro-, Latero-Flexion and Versions, Pro- 
lapse; Inversion].) 

2. Internal Examination ....... 249 

a. General Characteristics 249 

(Thickness of the Walls; Size; [Hydro-, Pyo-, 
Haematometra;] Color; Consistency; Men- 
strual and Puerperal Condition.) 

b. Special Morbid Conditions 251 

1. Lacerations . . . . . . . 252 

(Endometritis Gangrenosa; Perforation.) 

2. Inflammation 252 

(Endometritis Diphtheritica ; Haematoma 



TABLE OF CONTENTS. xxvil 

PAGB 

Polyposum ; Thrombophlebitis Placenta- 
ris; Metritis Phlegmonosa; Endometritis 
Catarrhalis, Hemorrhagica, Fibrosa, Cys- 
tica, Prolifera; Polypus Hydatidosus; Me- 
tritis Chronica; Erosions; Acne Cervicis 
Uteri.) 

3. Tumors ........ 257 

(Tuberculosis; Carcinoma; Fibromyoma 
(Subserous, Intraparietal, Submucous ;) 
Cavernous Fibroma; Myxomyoma; Myo- 
sarcoma; Sarcoma.) 

4. Congenital Malformations 261 

(Uterus Duplex, Bicornis, Septus.) 

h. Parametrium and Broad Ligaments 262 

(Thrombophlebitis; Lymphangitis; Phlegmonous Inflam- 
mation; Thrombosis [Phlebolites] ; Cysts; Cancer; Al- 
terations in the Lymphatic Glands.) 

I. Fallopian Tubes 264 

(Catarrh; Purulent Inflammation; Tuberculosis; Hydrops 
Tubse; Pyosalpinx; Rupture.) 
m. Ovaries 265 

a. External Examination ...... 265 

(Position; Size; Shape; Color; Consistency.) 

b. Internal Examination 266 

(Vascular Injection ; Color.) 

1. Follicles . 266 

(Corpus Luteum ; Fibroma Folliculi; Hydrops 

Folliculorum ; Oophoritis Apostematosa Fol- 
licularis.) 

2. Stroma . . . . . . . . .267 

(Oophoritis Phlegmonosa ; Chronica Fibrosa.) 

3. Tumors 268 

(Cystoma ; Fibroma ; Fibromyoma ; Sarcoma ; 
Carcinoma; Dermoid.) 
n. Pelvic Peritoneum . . . . . . . .270 

(Perimetritis ; Perioophoritis Chronica Adhsesiva ; Hema- 
toma Retro-uterinum ; Pelvic Peritonitis ; Tuberculosis ; 
Carcinoma ; Echinococci. ) 

Extra-uterine Foetation 272 

(Abdominal, Tubal, Ovarian; Lithopredion.) 
o. Rectum . . . . . . . . . .2 73 

a. General Characteristics . . . . . . 2 73 

(Prolapsus Ani.) 



XXV1U TABLE OF CONTENTS. 

PAGE 

b. Special Morbid Conditions 274 

(Hemorrhoids ; Proctitis ; Syphilitic and Diphtheritic 
Ulcers; Periproctitis; Polypi; Proctitis prolifera; 
Carcinoma'; Melanoma; Atresia Ani.) 
6. Duodenum and Stomach 278 

a. External Examination . . . . . . , 278 

1. General Characteristics 278 

(Size; Shape; Position; Color; Consistency.) 

2. Changes in the Serous Coat 280 

(Perigastritis Chronica, Purulenta ; Lymphangitis 
Purulenta ; Perigastritis Tuberculosa, Carcinoma- 
tosa; Perforation.) 

b. Internal Examination 282 

1. Contents 283 

(Blood; Undigested Food; Thrush; Leptothrix; Yeast 
Fungus; Sarcina.) 

2. Duodenal Mucous Membrane 285 

(Chronic Ulcers, etc.) 

3. Gastric Mucous Membrane 285 

a. General Appearances 286 

1. Secretion 286 

2. Volume 286 

3. Vascular Injection and Color . . . 287 

4. Post-mortem Changes 287 

(White and Brown Softening.) 

b. Special Morbid Conditions 288 

1. Inflammation ....... 288 

(Catarrh; Gastritis Prolifera; Gastritis Glan- 
dularis, Phlegmonosa.) 

2. Haemorrhage 289 

3. Simple Ulcer . . . . . . 290 

(Hemorrhagic Erosions; Round Ulcer.) 

4. Tumors 291 

(Tuberculosis; Lymph Follicles ; Carcinoma; 
(Glandular Cancer ; Scirrhus ; Colloid ;) 
Sarcoma; Myoma; Lipoma.) 

5. Amyloid Degeneration 294 

c. The Stomach in Cases of Poisoning . . . 295 

1. Method of Examination 295 

2. Changes Produced in Poisoning . . . 297 

a. Corrosive Poisons 297 

b. Phosphorus and Arsenic . 298 



TABLE OF CONTENTS. xxix 

PAGE 

7, LlGAMENTUM HePATO-DUODENALE 299 

a. Common Bile-duct 299 

(Permeability; Size; Color; Ulceration; Stenosis; Puru- 
lent and Diphtheritic Inflammation; Tumors.) 

b. Portal Vein 301 

(Periphlebitis Portalis ; Thrombosis; Thrombophlebitis.) 

8. Gall-bladder and Liver 302 

(Removal.) 

a. Gall-bladder 302 

1. External Examination 302 

a. General Appearances 302 

(Size; Shape; Color; Consistency.) 

b. Serous Coat 303 

(Pericystitis Fellese; Perforation.) 

2. Internal Examination 304 

a. Contents 304 

(Concretions; Hydrops Vesicae Fellese.) 

b. The Walls 306 

(Inflammation ; Ulceration ; Diphtheritis ; 
Phlegmonous Inflammation ; Scirrhus.) 

b. Portal Fissure and Lymphatic Glands . . . .307 

(Cheesy and Cancerous Degeneration.) 

c. Liver 307 

1. External Examination 307 

a. General Appearances 307 

(Weight; Color; Size; Shape; Consistency.) 

b. Capsule of the Liver 311 

(Perihepatitis Chronica Fibrosa, Adhaesiva ; 
Tuberculosis; Carcinoma.) 

2. Interior of the Liver 311 

a. General Appearances 311 

1. Parenchyma as a Whole . . . .311 

(Vascular Injection; Color; Consistency.) 

2. Lobules 313 

(Size ; Shape ; Color [Recognition].) 

b. Special Morbid Conditions 316 

1. Atrophy . . . . . . 316 

(From Pressure ; Brown ; Melanromic ; Cy- 
anotic ; Yellow and Granular Atrophy.) 

2. Hypertrophy 317 

(General ; Circumscribed.) 

3. Fatty Infiltration 318 

(Fatty Liver; Icterus; Nutmeg Liver.) 



TABLE OF CONTENTS. 

PAGE 

4. Amyloid Degeneration 320 

5. Inflammation 321 

a. Parenchymatous ..... 321 

(Cloudy Swelling ; Fatty Degenera- 
tion; Phosphorus Liver; Acute Yel- 
low Atrophy.) 

b. Metastatic ...... 324 

c. Interstitial . . . . . 325 

1. Acute 325 

(Hepatic Abscess.) 

2. Chronic 326 

(Granular Atrophy ; Cirrhosis; 
Lobulated Liver.) 

3. Syphilitic 328 

(Gummous.) 

6. Tumors 328 

a. Gumma 328 

(Hereditary Syphilis) 

b. Tubercle 328 

(Disseminated; Of Gall-ducts.) 

c. Lymphoma 329 

(Typhoid; Leucaemia.) 

d. Carcinoma ...... 330 

(Primary, Metastatic, Scirrhous, Me- 
dullary Cancer; Cancerous Throm- 
bosis.) 

e. Melanoma; Carcinoma; Cysts . . 331 

7. Parasites 332 

a. Echinococcus 332 

(Echinococcus Uniloculars, Multilo- 
cularis.) 

b. Pentastomum 333 

c. Distoma 333 

Pancreas. 333 

a. Parenchyma 334 

1. Atrophy ' . .334 

(Fatty Infiltration.) 

2. Parenchymatous Inflammation 334 

(Hseinorrhage.) 

3. Interstitial Inflammation' 334 

4. Carcinoma 335 

5. Congenital Anomalies ....... 335 

(Supplementary Spleen and Pancreas.) 



TABLE OF CONTENTS. xxxi 

PAGE 

6. Amyloid Degeneration . . . . . . 335 

b. Execretory Ducts 335 

(Cysts; Acne Pancreatica; Ranula Pancreatica; Calculi.) 

10. Cceliac Ganglion 336 

(Atrophy ; Pigmentation ; Amyloid Degeneration.) 

11. Mesentery 336 

a. Connective Tissue . 337 

(Haemorrhage ; Phlegmonous, Chronic Fibrous Inflam- 
mation ; Tubercle ; Carcinoma ; Fibroma ; Dermoid ; 
Chylangioma.) 

b. Lymphatic Glands . . . . . . . .337 

(Inflammation ; Typhoid Fever : Tuberculosis ; Tabes 
Mesenterica; Calcification; Leucaemia; Malignant Pus- 
tule ; Carcinoma ; Amyloid Degeneration.) 

c. Blood Vessels 340 

(Thrombosis ; Embolism.) 

12. Intestine 340 

a. External Examination . . . . . . .340 

1. General Appearances ...... 340 

(Size ; Color.) 

2. Peritoneal Coat 341 

(Tuberculosis; Necrosis; Typhoid Fever; Strangu- 
lation ; Ulceration ; Lipoma ; Diverticula ; Con- 
genital Fistula and Obliteration.) 

b. Method of Opening the Intestine 344 

c. Contents 346 

1. General Characteristics . . . . . ,346 

(Quantity; Color; Consistency; Odor.) 

2. Abnormal Constituents 347 

(Undigested Food ; Mucus; Epithelium; Trichina?; 
Taenia Solium and Mediocannelata ; Bothryoceph- 
alus; Ascaris; Oxyuris; Trichocephalus ; Cerco- 
monas; Schistomycetes.) 

d. Walls of the Intestine 352 

1. General Characteristics 352 

a. Increase in Volume . . . . . .352 

(Folds; Villi; Follicles.) 

b. Color and Vascular Injection .... 353 

2. Special Morbid Conditions 354 

a. Hemorrhages 354 

(Embolic Abscesses and Ulcers ; Varices.) 

b. Inflammation 355 

1. Catarrh 355 



xxxii TABLE OF CONTENTS. 

PAGE 

(Acute ; Chronic ; Enteritis Prolifera ; 
Chronic Dysentery ; Enteritis Chronica 
Cystica.) 

2. Enteritis Phlegmonosa ..... 356 

(Mycosis Intestinalis ; Follicular Abscess- 
es.) 

3. Enteritis Follicularis 357 

(Follicular Abscesses and Ulcers.) 

4. Enteritis Diphtheritica . . . . .357 

(Dysenteria Diphtheritica, Gangrenosa, 
Diphtheritis Follicularis; Impaction of 
Fasces ; Cholera ; Puerperal Affections ; 
Typhoid Fever ; Variola, etc.) 

5. Scrofulous and Tuberculous Enteritis . .361 

(Cheesy Degeneration of the Follicles ; 
Tuberculous Ulcers.) 

6. Typhoid Fever 363 

(Medullary Swelling ; Sloughs; Typhoid 
Ulcers ; Perforation ; Haemorrhage.) 

c. Tumors 366 

d. Amyloid Degeneration 366 

Vermiform Appendage 367 

(Displacement; Hydrops; Concretions; Ulcer; 
Perforation ; Perityphlitis ; Thrombophlebi- 
tis.) 
13. Great Vessels and Adjacent Lymphatic Glands . 369 

a. Veins . 369 

Thrombosis 369 

(Organization ; Sinus-like Metamorphosis ; Phlebo- 
lites.) 

1. Thrombophlebitis 371 

2. Cancerous Thrombi . . . . . . 372 

3. Acute Primary Inflammation . . . . .372 

(Phlebitis Pseudo-pustulosa ; Peri- and Paraphle- 
bitis.) 

4. Chronic Inflammation . . . . ". .372 

5. Varices ........ 372 

b. Arteries . . . . . . . . . .372 

1. General Characteristics . . . . . . 373 

(Width ; Thickness of Walls ; Elasticity.) 

2. Special Morbid Conditions, particularly of the Intima 374 

1. Retrograde Metamorphosis . . . . .374 
(Gelatinous Metamorphosis; Fatty Degenera- 



TABLE OF CONTENTS. xxxiii 



PAGB 



tion of the Intima ; Fatty Erosions ; Rup- 
ture.) 

2. Inflammation . . . . . .375 

(Sclerosis ; Atheromatous Abscess ; Atheroma- 
tous Ulcers ; Parietal Thrombosis ; Calcifica- 
tion.) 

3. Calcification of the Media 377 

(Senile Gangrene.) 

4. Aneurisms ....... 377 

(Aneurysma Serpentinum, Cylindriform, Fusi- 
form, Sacculatum, Dissecans, Traumaticum, 
Varicosum.) 

5. Congenital Alterations . . . . . .379 

(Stenosis and Atresia; Hypoplasia [Aorta Chlo- 
rotica].) 

c. Retroperitoneal Lymphatic Glands ..... 380 

(Inflammation; Tumors, etc.) 

d. Thoracic Duct 380 

(Receptaculum Chyli.) 

14. Internal Muscles of the Trunk 381 

a. Diaphragm. ......... 381 

(Trichinae; Diaphragmatitis.) 

b. Psoas 381 

(Psoas Abscess ; Tumors.) 

15. Front of the Spine 382 

a. General Characteristics . . . . . .. .382 

(Scoliosis ; Kyphosis ; Lordosis ; Pott's Disease.) 

b. Special Morbid Conditions 384 

(Fractures and Dislocations; Spondylarthrocace ; Prever- 
tebral Abscesses ; Cheesy Osteomyelitis ; Supracarti- 
laginous Exostoses ; Sarcoma ; Carcinoma.) 

16. Pelvic Bones 385 

a. General Characteristics 385 

(Deformity ; Narrow Pelvis ; Pelvis altered in Osteo- 
malacia and Rickets.) 

b. Special Morbid Conditions 386 

(Fractures; Caries; Exostoses [Spinous Pelvis]; Enchon- 
droma; Osteoma; Sarcoma; Carcinoma.) 

IV. EXTREMITIES . . . . 387 

I. Lymphatic Glands 387 

(Lymphadenitis and Periadenitis Apostematosa Chronica ; 



xxxiv TABLE OF CONTENTS. 

PAGE 

Cheesy Inflammation ; Syphilis ; Leucaemia ; Lymphosar- 
coma ; Cancer.) 

2. Lymphatic Vessels 388 

(Enlargement ; Elephantiasis ; Lymphangitis ; Perilymphan- 
gitis.) 

3. Blood-vessels 389 

4. Nerves 389 

(Atrophy; Inflammation; Neuroma; Fibroma; Myxoma; Sar- 
coma ; Carcinoma.) 

5. Muscles 390 

a. General Characteristics 390 

(Size ; Color ; Consistency.) 

b. Special Morbid Conditions 390 

1. Hypertrophy 390 

(True Hypertrophy; Fatty Infiltration.) 

2. Atrophy 391 

(Atrophy from Fatty Infiltration; Atrophia Fusca; 
Atrophy from Fatty Degeneration ; Atrophia Sim- 
plex.) 

3. Haemorrhages 392 

4. Inflammation 392 

a. Parenchymatous 392 

(Typhoid Fever; Hyaline Degeneration.) 

b. Interstitial 393 

(Purulent, Chronic Fibrous, Ossifying; Parosteal 
Exostoses.) 

5. New Formations ........ 394 

(Tubercles ; Gummata ; Sarcoma ; Myxoma ; Carci- 
noma; Fibroma; Lipoma.) 

6. Parasites . . . ... . . .395 

(Trichina?; Cysticercus; Echinococcus.) 

6. Joints 395 

a. External Examination . . . . . . . 396 

(Distention of Capsule; Anchylosis; Perforation; Disloca- 
tion; Partial Dislocation.) 

b. Internal Examination . . . . . . . .397 

1. Contents 397 

(Serous; Fibrinous; Purulent Exudation ; Free Bodies.) 

2. Internal Ligaments . 398 

3. Synovial Membrane 398 

(Haemorrhages ; Tubercles ; Villi ; Lipoma Arbores- 
cens ; Ulcerations.) 

4. Articular Surfaces . . . . . . .399 



TABLE OF CONTENTS. xxxv 

PAGE 

a. Cartilage 399 

(Excrescences ; Atrophy ; Chondromalacia ; 
Erosions ; Necrosis ; Fibrillation ; Fibrous 
Degeneration.) 

b. Ends of the Bones 400 

(Caries ; Attrition.) 

c. Articular Sockets 402 

(Erosions; Disappearance.) 
5. Special Morbid Conditions 402 

a. Inflammation 402 

(Arthritis Kheumatica Sicca, Fibrinosa, Adhse- 
siva, Chronica Deformans, Arthritis, Syphili- 
tica ; Arthritis Purulenta Acuta ; [Perforation ; 
Periarticular Abscess ; Caries ;] Arthritis ; 
Purulenta Chronica vel Tumor Albus; Caries 
Fungosa ; Arthritis Urica.) 

b. Dislocations . . . . - . . .407 
7. Bones. 407 

(Removal of the Femur; Centre of Ossification in the Lower 
Epiphysis of the Femur of the New-born.) 

1. The Bones in General ........ 409 

(Number; Size; Shape; Color; Consistency; Fractures; 
Dislocations.) 

2. The Component Parts of Bone 411 

a. Periosteum . . . . . . ■ . .411 

1. General Appearances 411 

(Separation ; Injuries ; Defects ; Thickness ; 
Color; Consistency.) 

2. Special Morbid Conditions 411 

(Periostitis Ossificans; Osteophytes ; Callus ; 
Purulent, Cheesy, Gummy Inflammation ; Ex- 
ostoses; Osteosarcoma; Osteoid Tumors; Car- 
cinoma.) 

b. Osseous Tissue 414 

1. General Appearances 414 

a. Surface 414 

(Thickening ; Atrophy.) 

b. Interior . . . . . . . .415 

(Osteosclerosis ; Ostitis Ossificans ; Osteo- 
porosis ; Rarefying Ostitis ; Osteomalacia.) 

2. Special Morbid Conditions 41(5 

a. Inflammation 41G 

(Caries ; Necrosis.) 



xxxvi TABLE OF CONTENTS. 

PAGH 

b. Tumors 417 

(Enostoses ; Enchondroma ; Rachitis.) 

c. Changes in the Cartilage of the Epiphyses . 417 

(S} r philis; Cartilaginous Exostoses.) 
c. Marrow 418 

1. General Appearances 418 

(Amount; Color; Consistency). 

2. Special Morbid Conditions 419 

(Fatty Marrow ; Red and Gelatinous Marrow.) 

a. Inflammation 419 

(Osteomyelitis Ossificans, Purulenta, Icho- 
rosa, Caseosa.) 

b. Tumors 420 

(Gummata; Tubercle; Sarcoma; Myxo- 
ma ; Carcinoma.) 
3. Morbid Conditions of the Bones in General .... 422 

a. Fracture 422 

(Periosteal, Myelogenous, and Parosteal Callus; 
False-joint.) 

b. Rickets 423 

c. Inflammation ........ 424 

(Necrosis; Sequestrum.) 

d. Syphilis 424 

e. Tumors ......... 425 

Index ....... .... 427 



DIAGNOSIS IN PATHOLOGICAL ANATOMY, 



INTRODUCTION. 

The method of examination of the human body after death 
may vary according to the object in view. If this object be 
merely to confirm a diagnosis or to obtain more accurate 
knowledge of the condition of one or more special organs, 
the parts in question may be simply removed and examined 
out of the body ; but if we wish to obtain a clear and broad 
idea of the change in the general organism brought about by 
any disease, of the effects of the combination of different dis- 
eases, of latent morbid changes in this or the other organ, it 
is only by a thorough and methodical examination of the 
whole body that we can obtain our end. Again, our object 
may be to ascertain the cause of death. In this case, too, the 
examination must be thorough and methodical ; otherwise 
an important point might be easily overlooked. Finally, 
medico-legal cases may be put in a class by themselves, 
though they are partially included under the preceding divis- 
ion. It was formerly the custom to separate medico-legal 
from the so-called pathological autopsies, and in forensic cases 
to limit the examination to those changes which were imme- 
diately connected with the legal question at issue. But this 
was all wrong, for one can never know beforehand how im- 
portant the morbid condition of any special organ may be- 
come during the course of the investigation, nor is one in a 
position to give a final and weighty opinion as to the fatal 
disease, the cause of death, or the condition of particular 
organs, unless each and every organ in its individual and 



2 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

associated capacity has been accurately studied and made 
out. For these reasons the new Regulations for procedure in 
medico-legal cases in Prussia prescribe a careful and method- 
ical examination and description of all parts of the body in 
their several relations, and, at the present time, a medico- 
legal is only distinguished from a pathological autopsy in 
that everything which may serve the ends of justice is treated 
with even greater accuracy and detail than is the case in an 
ordinary autopsy. 

In order to make a thorough examination, it is absolutely 
essential to note accurately the relative position of each part 
to neighboring parts before disturbing them, and to take care 
that no part be removed if its removal interfere with the 
subsequent examination of other parts. 

The method prescribed in the Regulations is practically 
that which Virchow x introduced into the Pathological Insti- 
tute at Berlin ; it meets the above named requirements, and 
has, therefore, been used as the basis of the present volume. 
A few words only on necessary preliminaries and instruments. 

PRELIMINARIES. 
A room to be suitable for autopsies should be spacious, 
well ventilated, and well lighted, good light being indispen- 
sable for the recognition of the finer changes in the structure 
of organs. Artificial light is bad on account of its yellowness, 
which modifies the natural color of parts ; indeed, the Regu- 
lations do not allow an autopsy to be made by artificial light 
unless circumstances are such that it cannot be postponed. 
The best position for the operator is on the right of the body, 
and the table should be high enough to render much stooping 
unnecessary. It is true that in private houses, and in medico- 
legal cases, the external surroundings are often very unfavor- 
able, and it is not always easy to comply with these con- 
ditions, some ingenuity being necessary to contrive a suitable 

1 During the progress of this work, and in time to be available in its revision, 
Virchow himself has published a description of his method of conducting 
autopsies, — Die Sectionstechnik im Leichenhause des Charite-Krankenhauses, etc._. 
Berlin: Hirschwald, 1876. 



INSTRUMENTS. 3 

support for the body out of tables, chairs, blocks of wood, 
planks, etc. ; but one can nearly always get a table and an old 
door or some boards to lay upon it. The head, during the 
examination of the brain, or the back, during the examination 
of the neck, should be supported on a block of wood, with 
one edge rounded and hollowed at the middle, but if this be 
not at hand, any block of wood, or even a brick may be 
made to serve the purpose. 

In moving the body, and especially in moving it from one 
place to another, care should be taken that it be done gently, 
and that the great cavities be kept in the horizontal position 
as nearly as may be, lest a part be ruptured or dislocated. 

INSTRUMENTS. 

Section five of the Regulations contains a list of those 
which are most needful. 

Four to six scalpels, two small with a straight edge, and 
two larger with a bellied edge, a section-knife, two stout car- 
tilage knives, two pair of forceps, two double hooks, a pair of 
large scissors, with one blade blunted and the other sharp at 
the point, a pair of smaller scissors, one blade being probe- 
pointed, an enterotome, one coarse and two fine probes, a 
saw, a mallet and chisel, a pair of bone cutters, a blow-pipe 
with stopcock, six curved needles of different sizes (sail- 
needles), a pair of callipers, a meter or yard measure with 
fine divisions, a large graduated vessel for measuring fluids, 
scales with weights up to ten pounds, a good magnifying 
glass, blue and red test paper. Besides these it is desirable 
to have a double saw for opening the spinal canal (rachi- 
tome), one or two tenon saws which are very convenient in 
examining the bones at the base of the skull, sponges, and 
a little cup for scooping up small quantities of fluid. The 
sharper the knife the better, and it is not to be held like a 
pen, as in the dissecting room, but grasped firmly in the 
hand; incisions should be begun with the heel of the blade, 
not the point, and the knife swept along from the shoulder 
rather than the wrist, thus making a long, smooth cut. The 



4 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

larger an incision the more surface does it expose, and Vir- 
chow even affirms, i that a large cut, though made in the 
wrong place or direction, is, as a rule, preferable to one or 
many small cuts which are correct in these respects." It is 
also very important that incisions should be smooth, as may 
be insured by avoiding excessive pressure on the organ or 
part and drawing the knife firmly and steadily through it. 
This latter remark applies with especial force to the softer 
organs, and above all to the brain, in connection with which 
Virchow says, " better false cuts, if s?nooth, than jagged ones 
which are correct." 

The utmost possible neatness should be observed in every- 
thing, and a vessel of clean water should be constantly 
present to rinse the knife and hands when soiled ; the body 
also should be kept as clean as possible. Besides the vessel 
of water for the knife and hands, the use of which should be 
reserved exclusively for them, means should be provided for 
cleansing the organs as they are removed from the body ; a 
common watering-pot, from which the nose has been removed, 
answers this purpose remarkably well, and has the further 
advantage of enabling one to regulate the force of the 
stream of water at will. A special receptacle should be pro- 
vided for such waste as blood, exudations, transudations, 
etc. Shallow wooden dishes with raised edges are very con- 
venient ; one for receiving an organ during its examination, 
and a larger one for those organs which have already been 
examined. 

APPLIANCES FOR CHEMICAL AND MICROSCOPICAL EXAM- 
INATION. 

It is often convenient to have a microscope at hand for 
immediate use, though generally it will be found better to 
take home anything which requires the use of the microscope 
and there examine it at leisure. 

The following are the chief instruments necessary to pre- 
pare specimens for microscopic examination. A razor, sev- 
eral scalpels, scissors, forceps (those intended for coarser 



INSTRUMENTS. 5 

pathological work are rather clumsy, but may be used in 
default of better), a pair of stout needles set in handles, 
watch-glasses, object and cover glasses, a camel's hair-brush, 
bibulous paper, and a double knife, the latter almost indis- 
pensable for fresh specimens. Such a knife consists of two 
parallel blades, one of which is fixed in a handle and the 
other movable. The movable, by an arrangement of springs 
and screws, can be approximated as desired to the fixed 
blade, and both blades are ground plane on the juxtaposed 
surfaces. In using it care should be taken that the blades 
be as nearly parallel as possible, to insure uniform thickness 
of the section, and the degree to which they are approximated 
depends on the thickness of the section which is desired and 
the consistency of the organ to be cut. In general, if the 
organ be lax in structure the blades should be more widely 
separated than if it be dense. The knife should be dipped 
before using in a mixture of alcohol two parts, and water 
and glycerine in equal proportions one part, to prevent the 
section from adhering to the blade and being torn ; water 
alone does not moisten the knife uniformly enough. After 
the knife has been thus moistened it should be held like a 
fiddle bow, and the anterior extremities of the blades laid on 
that portion of the organ from which it is desired to obtain 
a section, and which should be put on the stretch in some 
way ; the section is then made by pushing the knife forward 
its whole length with moderate pressure downwards, and 
drawing it backwards again as far as necessary. Sometimes 
the section remains sticking in the organ after the knife has 
been drawn through it, but this may be obviated by giving 
the knife a slight sideward turn before withdrawing it. 

The character of the fluids in which a section is examined 
has much to do with its usefulness. Liquids can generally be 
examined in their natural condition, and for fresh sections, 
especially if reference be had only to relatively coarse path- 
ological changes, common water usually suffices. But if 
more delicate examination be desired, and especially if it be 
the object to preserve blood corpuscles in as natural a con- 



6 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

dition as possible, a so-called "indifferent " fluid must be 
made use of. This fluid may be one which is found already 
formed in the organism, as the aqueous humor or serum, or 
may be artificially prepared. A one half to one per cent, 
solution of common salt usually answers very well. Both 
iodine and osmic acid have the property of hardening pro- 
toplasm, and hence are often of great value, especially when 
the cells are very delicate and easily broken up ; the latter 
may be used in very dilute solution — one eighth to one 
tenth of one per cent. Tincture of iodine being in frequent 
demand as a reagent, it is well to keep the following solution 
on hand : Iodine one part, potassic iodide three parts, water 
one hundred parts. Before addition to a microscopic prep- 
aration this solution should be diluted to a pale yellow color 
with water. Stained specimens are generally examined 
either in glycerine or a concentrated solution of potassic 
acetate ; the parts which are not acted upon by the coloring 
matter are thus rendered more transparent, and the stained 
parts become still more prominent. 

One of the most important reagents, on account of its prop- 
erty of rendering connective tissue more transparent as well 
as of contracting the nuclei and thus bringing them out more 
clearly, is acetic acid, which should always be on hand 
both in the anhydrous (glacial acetic acid) and in the di- 
lute form (one to five per cent.). Caustic soda or potassa 
should also be on hand ; their chief use is in the detection 
of fatty granules which they do not dissolve, while they do 
dissolve all soft tissues except elastic tissue. It is well to 
have two solutions of the alkali, one of one per cent., and one 
of thirty-three to thirty-five per cent. Finally, one should 
have a five to ten per cent, solution of muriatic acid as a 
solvent of the salts of lime. The best way of using these 
reagents is to allow a few drops to flow from one side of the 
cover glass to the preparation while a bit of bibulous paper 
on the other side absorbs the fluid which is under the glass ; 
the action of the reagent on the preparation can thus be fol- 
lowed step by step under the microscope. If a current be 



REAGENTS. 7 

thus developed strong enough to carry the specimen out of 
the field, one of the following methods must be resorted to : 
one drop of the reagent may be placed at the edge of the 
cover glass and allowed to diffuse itself gradually underneath, 
in which case somewhat stronger solutions should be used ; 
or else, abandoning the idea of watching the actual action of 
the reagent, the preparation may be from the commence- 
ment examined in a drop of the solution. 

Much may often be gained, even in the examination of 
fresh specimens, by the employment of various coloring mat- 
ters, all of which have this in common, that they stain the 
protoplasm (especially the nuclei), either exclusively or at any 
rate more deeply than the intercellular substance. Methyl- 
aniline is a very convenient coloring matter on account of the 
rapidity with which it acts, and in an aqueous solution of one 
to one thousand stains the nuclei of the cells a beautiful blue 
in a few minutes. The fact that it stains bright red those 
tissues which have undergone amyloid degeneration, adds to 
its value. After removal from this staining fluid the prepara- 
tion should be washed and then examined, in either water or 
a concentrated solution of potassic acetate ; the color fades 
rapidly in glycerine. Hoematoxyline is also a valuable color- 
ing matter. The following formula for its preparation is that 
recommended by E. Klein : — 

Rub together thoroughly 5 grams of the officinal extract of haenia- 
toxyline and 15 grams of powdered alum in a mortar, adding gradu- 
ally 25 cubic centimeters of distilled water ; filter and add to the filtrate 
5 grams of alcohol. Rub the residue again in a mortar with 15 c. c. of 
water, which should be added gradually, and add, after filtering again, 2 
grams of alcohol to the filtrate. Mix the two fluids, and preserve in 
a well stoppered bottle. If it become turbid filter again. For use put sev- 
eral drops into a watchglass full of distilled water. After straining put 
the preparations for some minutes into distilled water and examine in 
pure glycerine or a solution of potassic acetate. 

The inconvenience of haematoxyline is that the color is 
decomposed by the presence of the smallest quantity of any 
acid, while though acetic acid destroys the above mentioned 
aniline color, a preparation may be restained in it even after 



8 DIA GNOSIS IN PA THOL GICAL ANA TO MY. 

it has been boiled in glacial acetic acid. Carmine is not af- 
fected by acids at all, but is not so well adapted for rapid 
tingeing, as it then stains the interstitial tissue somewhat, as 
well as the protoplasm. 

A neutral solution of carmine may be prepared by rubbing powdered 
carmine with an equal amount of concentrated aqua ammonia, and 
leaving the mixture exposed to the air in an open glass till it has become 
perfectly dry. Then dissolve the resulting powder in a quantity of dis- 
tilled water equal to three times the original mixture, filter, and add one 
gram of carbolic acid for every hundred cubic centimeters of the so- 
lution as a preservative (Ranvier). This strong solution may be diluted 
before using if desired. 

After staining in carmine, preparations should be washed 
in water, then put for a few minutes into a one per cent, so- 
lution of acetic acid, and examined in glycerine or potassic 
acetate. 






EXAMINATION OF THE BODY. 



Two grand divisions may be made of every autopsy : — 

A. External examination or inspection. 

B. Internal examination or section. 

A. INSPECTION. 

In medico-legal cases, especially, this may yield impor- 
tant information, — as to the time when death occurred, 
the manner of it, etc., — but in purely pathological cases the 
external appearances are, as a rule, of very subordinate in- 
terest. It scarcely lies within the scope of this compend 
to treat exhaustively those conditions which are important 
solely from the point of view of legal medicine, and the reader 
is therefore referred for the discussion of such to the text- 
books of medical jurisprudence, while we propose to confine 
ourselves to those points which are of importance in patho- 
logical as well as in most medico-legal cases. 

Inspection may be general or special ; general as applied 
to the condition of the body as a whole, and special as ap- 
plied to the condition of its several parts. 

I. INSPECTION OF THE BODY AS A WHOLE, 
(a.) GENERAL ATTRIBUTES OF THE BODY. 

Under this head may be included age, sex, stature, frame, 
general nutrition, and general character of the skin. 

The frame may be powerful, feeble, delicate, deformed, 



10 DIA GNOSIS IN PA THOL OGICAL ANA TO MY. 

etc. ; if deformed, rachitis is generally the cause. The 
degree of general nutrition is indicated by fullness and 
roundness of form or their absence, and by the degree of 
prominence and thickness of the muscles. Emaciation may 
be dependent on either of two conditions : 1st. On atrophy 
of the fatty layer of the skin, in which case the integument 
is loose, and can everywhere be raised up in large thin folds. 
If a fold be rolled between the ringers it is easy to appre- 
ciate by the sense of touch the amount of subcutaneous fat. 
It is also evident that the thinner the integument the more 
sharply will the contour of the muscles be defined. 2d. On 
atrophy of the muscles, in which case they are thin and 
slender, their contours are ill-defined, the prominence of the 
biceps and the calf of the leg have disappeared, etc. Of 
course both these forms of atrophy are very often associated, 
and, indeed, in many wasting diseases but little more than 
skin and bones are left. 

In raising a fold of skin we can also determine its tension 
and elasticity ; the former is in an inverse ratio to the length 
of the uplifted fold. If the elasticity be normal the fold will 
resume its former position as soon as it is released ; sometimes, 
in those dead of cholera, for example, it does not do this. 

The general color of the skin should also be noted, and 
this can be properly done only when the body is clean. The 
usual color is pale grayish white, and is most marked on those 
parts of the body which have been protected by clothing. 
Those parts which have become browned by exposure to 
light and air during life remain so after death, and one 
sometimes meets with individuals, generally from the lower 
classes of society, in whom this is so marked and so widely- 
extended over the neck and chest, that one is almost in dan- 
ger of confounding it with that bronzed hue of the skin which 
is so prominent a feature in Addison's disease. This latter 
hue, however, extends over the whole body, and is especially 
marked on the belly, while if the brownish color be due to 
atmospheric influence, such is not the case. It may as well 
be incidentally mentioned here that the bronzing of the 



INSPECTION. 11 

skin, even if it extend to the mucous membrane of the mouth, 
does not point with absolute certainty to disease of the supra- 
renal capsules. These bodies may be diseased and the skin 
not bronzed, and the reverse. The coloring matter of the 
bile gives rise to a uniform pale yellow (lemon color) dis- 
coloration of the skin (icterus), which is usually most marked 
in the face and on the forehead. If the jaundice be of long 
duration and very intense, the discoloration may be dark yel- 
low or even nearly black (icterus melas). A waxy pallor of 
the skin indicates ancemia or oligcemia, either acute (from 
loss of blood) or chronic. A clayey tinge is associated with 
various cachexias, such as carcinoma, etc. ; and a peculiar 
dirty grayish hue, especially on those parts which have been 
exposed to the sunlight, occurs in those who have been tak- 
ing the salts of silver for a long time (argyria). 

(b.) SIGNS OF DEATH AND DECOMPOSITION. 

Those changes of color in the skin which result from de- 
composition, naturally lead to the consideration of the signs of 
death and commencing putrefactive change, and are of im- 
portance in all cases on account of the light which they throw 
on the condition of the internal organs. In medico-legal 
cases their importance is still greater. Two different kinds 
of discoloration are to be carefully distinguished from each 
other : 1st. A greenish discoloration which is due to decom- 
position in the tissue, and first appears in those situations 
where the viscera lie nearest the surface, at the sides of the 
belly, the intercostal spaces, etc. 2d. That light or dark red, 
faded red, or livid discoloration which occurs in underly- 
ing portions of the body in discrete spots (suggillations), or 
more or less uniformly diffused over the body, and is due to 
blood. These spots, again, may be divided into two classes ; 
those which depend on simple gravitation of the blood within 
the vessels (hypostasis, hypostatic spots), and those which 
depend on diffusion of the coloring matter of the blood in 
the vessels into the surrounding tissue. These conditions are 
readily distinguishable. If the discoloration be due merely 



12 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

to gravitation it disappears on pressure, but if it be due to 
diffusion of the coloring matter of the blood, though origin- 
ally less distinct, it does not disappear. Dull livid streaks, 
which are due to diffusion of the coloring matter of the blood 
from the larger cutaneous veins, indicate a high degree of the 
latter condition. Sometimes the whole venous cutaneous net- 
work is thus mapped out, as it were. In the usual position 
of the body these discolorations appear first and most mark- 
edly on the back and neck ; but they appear first on the chest, 
neck, and face, if these parts happen to have been undermost. 
This fact should be borne in mind to avoid the error of con- 
sidering a normal post-mortem appearance to be of cyanotic 
or pathological nature. 

In medico-legal cases these post-mortem discolorations 
(which never give rise to elevation of the surface) should al- 
ways be incised, to avoid the risk of confounding them with 
extravasations of blood. In the hypostatic form fluid blood 
from the small vessels which are severed appears on the cut 
surface of the undiscolored tissue ; diffusion of the coloring 
matter of the blood is indicated by diffuse redness which per- 
sists even ' after pressure ; while extravasation, which more 
often causes slight elevations of the surface, is shown by 
the presence of blood, whether fluid or coagulated, in the tis- 
sue itself, more or less of which blood can generally be re- 
moved. The more fluid the blood in a body (as in cases of 
suffocation, of the acute infectious diseases, etc.), the more 
numerous and extensive are the post-mortem discolorations. 

Cadaveric rigidity is another important sign of death. It 
appears first in the muscles of the jaw, gradually progresses 
from above downwards, and disappears in the same sequence. 
The more robust the individual and the shorter the duration 
of the disease, the more marked and persistent is this mus- 
cular rigidity, which attains its maximum in cholera. The 
sharply defined and thick bellies of the muscles, the contrac- 
tion of which can scarcely be overcome, combined with the 
cyanotic hue of the skin, enables us to recognize this disease 
from a distance. Cadaveric rigidity disappears earliest in 






INSPECTION. 13 

those dead of a disease attended by hectic. After having 
been forcibly overcome it does not reappear. 

II. INSPECTION OF THE SEVERAL PARTS OF THE BODY. 

In examining the several parts of the body, one should be- 
gin with the head, and then take up in order the neck, the 
chest, the abdomen, the surface of the back, the anus, the 
external genital organs, and, finally, the extremities. In 
medico-legal cases special regard must be paid to the possible 
presence of foreign bodies or substances in the natural outlets 
of the body, the condition of the teeth, the condition and 
situation of the tongue, and, finally, the presence of injuries. 
Evidences of suppuration, of the formation of granulations or 
cicatricial tissue in a wound, the presence of gaping edges 
with adherent coagulated blood, warrant with more or less 
certainty the conclusion that the wound occurred before 
death. 

Further changes to be noted are : — 

(a.) Modifications of Size and Form. — Under this head 
are included distention and retraction of the abdomen, also 
swelling, especially of the extremities, due to oedema of the 
skin and subcutaneous cellular tissue. The latter is made evi- 
dent by the doughy consistency of the parts, and the fact that 
they pit on pressure. On section the fatty tissue is flabby 
and infiltrated with clear fluid, which gradually collects more 
and more in the lowest part of the cut ; if the oedema has ex- 
isted for a long time the connective tissue is white and thick- 
ened. It is noteworthy that in trichinosis, where an (Edem- 
atous swelling exists in the neighborhood of striped mus- 
cular fibre, there is no oedema of the external genitals, which 
become so extensively cedematous in other affections. Be- 
sides the relative proportion of the parts in general, that of 
the skin and its component parts are also to be noted. The 
epithelium and the true skin, one or both, may be either 
thickened or atrophied, and an idea of their relative propor- 
tion is to be obtained by incisions in several places. 

(6.) When noting the color of a part it must be borne 



14 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

in mind that when the color of parts depends on the amount 
of blood in the vessels, they generally lose it after death in 
great measure. Yet the bluish or livid hue of the nose, lips, 
ends of the fingers, etc., called " cyanotic," which depends 
on venous stasis, and is generally associated with dilatation 
of the vessels, is usually quite distinct after death. The 
presence of changes due to extravasation of blood should be 
carefully noted. Sometimes these are of large extent (trau- 
matic), sometimes small or even punctate (purpura haemor- 
rhagica, acute hemorrhagic exanthemata, ulcerative endocar- 
ditis). When post-mortem discoloration can be excluded, 
indistinct redness of the skin points to extravasation before 
death, while a yellowish or greenish yellow zone around an 
extravasation (partial haematogenous icterus) shows that it 
is of some standing. 

A brownish discoloration, especially when occurring in nu- 
merous small, scattered spots, is generally the result of cir- 
cumscribed inflammatory processes, and hence is often met 
with near scars — in connection with ulcers of the leg, for 
instance ; or else it is congenital, as in pigmentary nsevi. 
White cicatrices are also met with ; their effect is striking in 
proportion to the degree of pigmentation of the rest of the 
skin (in Addison's disease, for example, they are very con- 
spicuous) ; irregular white spots (partial albinismus) are 
sometimes met with, especially on the genitals. 

III. INSPECTION OF NEW-BORN CHILDREN. 

It being often of the utmost importance to decide as to 
the viability and period of development of a new-born child, 
we will now take up systematically the points which aid in 
the solution of these questions, and which have not already 
been mentioned. 

The average length of new-born children at full term is 
50-51 cm., the figures being rather larger for boys than for 
girls. During the last five lunar months of foetal life the 
length in centimeters is five times the number of the lunar 
month which the child has reached in its development (at the 



INSPECTION. 15 

sixth month 5x6=30, at the eighth month 5 X 8 = 40, 
etc). The average weight of boys at full term is 3,300 grams, 
that of girls, 3,250 grams. The normal skin is firm and 
somewhat on the stretch, not wrinkled ; its color is no longer 
red but white, and it is more or less covered with light 
downy hairs. At full term this down is chiefly marked on 
the shoulders. The umbilical cord, the average length of 
which is about 48-56 cm., is inserted somewhat below the 
middle of the body and falls off from five to eight days after 
birth. 

The head should be examined with great care. The 
length of the hair should first be noted : at full term this is 
generally 2-3 centimeters. Next the size of the fontanels ; 
the anterior or great fontanel measures 2-2.5 cm. in length 
at full term. Next come the different measurements of the 
head — the circumference of the head, 34.5 cm. ; the longi- 
tudinal diameter from the glabella to the occiput, 11.5 cm. ; 
the anterior transverse at the end of the coronal suture, 8 
cm. ; the posterior transverse at the eminences of the pari- 
etal bones, 9 cm. ; the long oblique, from the chin to the high- 
est point of the occiput, about 13.5 cm. ; the short oblique, 
from the anterior border of the nape of the neck to the far- 
thest point of the forehead (inexact), about 9.5 cm. Then the 
eyes should be examined, the pupillary membrane disappear- 
ing about the commencement of the eighth lunar month. 
The cartilages of the nose and ears are hard to the touch at 
full term. The finger nails are hard and horny, and project 
somewhat beyond the end of the fingers. The width of the 
shoulders should also be measured (11 cm.), and likewise 
the distance from one trochanter major to its fellow (9 cm.). 
Finally, the genitals should also be examined. The testicle 
descends into the scrotum during the seventh month, and at 
full term both testicles should occupy the wrinkled scrotum. 
In girls at full term the labia majora are generally long 
enough to hide the clitoris and labia minora, though this is 
not always the case. (We shall speak of the examination 
of the centre of ossification of the femur under the head of 
Bones of the Extremities.) 



16 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

IV. MORBID CONDITIONS OF THE SKIN AND SUBCUTANEOUS 
CELLULAR TISSUE. 

Before entering on the consideration of morbid conditions 
of the skin and subcutaneous cellular tissue, we must state 
that we do not consider it to lie within the scope of this 
work, which is only a compend of diagnosis in pathological 
anatomy, to treat exhaustively all those diseases of the skin 
which may be met with in the dead body, but which are to 
be seen in their full development only during life and are 
described in the text books of dermatology. We shall dis- 
cuss in detail only those modifications which are, or may be, 
connected with disease of the internal organs, or which have 
special pathologico-anatomical interest. 

(a.) GENERAL MORBID CONDITIONS. 

1. On our way from without inwards we first come to cer- 
tain changes in the epidermis. The first of them to be 
mentioned is abnormal separation or detachment of the 
upper horny layers. While from healthy skin the older 
layers of the epidermis are gradually and insensibly cast off, 
the epidermis is often cast off in larger or smaller coherent 
masses, not only as a result but also as a part of many cuta- 
neous affections. In psoriasis and pityriasis versicolor, des- 
quamation takes place in small scales, which in the latter 
disease are distinguished by their brownish shade ; rather 
larger masses are shed after many of the acute exanthemata 
— measles, for example ; finally, if the epidermis be detach- 
able in large strips, or from a whole finger or hand, scarla- 
tina is pretty clearly indicated. The desquamation from an 
otherwise healthy skin should not be confounded with the 
post-mortem detachment of epidermis over inflamed surfaces 
as in erysipelas, or with the same condition resulting from 
inflammation of the subcutaneous cellular tissue (phlegmon), 
in which cases the surface from which the epidermis has be- 
come separated is always moist and usually reddened or of a 
dirty greenish color. A like condition may be met with, not 






SKIN AND SUBCUTANEOUS TISSUE. 17 

dependent on inflammation but on decomposition. In this 
case other evidences of decomposition will also be present 
and prevent our falling into error. 

The epidermis may be separated from the true skin by 
circumscribed collections of fluid (blisters), which are gene- 
rally of a pale, dirty-red color, when the result of decompo- 
sition. The same appearance may be met with in fresh 
bodies, provided that decomposition had begun during life, 
— over spots of gangrene, for example. 

An eruption of small vesicles, attended with but slight ele- 
vation of the epidermis, is not an accidental complication, 
but rather an actual morbid condition. According to the 
character of the contents, a distinction is drawn between 
vesicles or bullce, both of which contain a clear watery fluid, 
and differ only in size, and pustules, which contain pus. 
The latter may be a later stage of the former, in which case 
both are found associated. 

2. The integrity of the deeper layers of the skin, the cutis 
proper, depends on that of the epidermis. If the latter be 
detached from any cause, the cutis dries by evaporation into 
a stiff brown parchment-like substance. Whether this dry- 
ing up involves only the upper layers of the cutis, or its 
whole thickness, is readily seen on cutting into it. Great 
distention or pressure may cause atrophy of the cutis ; hyper- 
trophy, however, is more common. If such hypertrophy take 
the form of hard elevations from the size of a hempseed to 
that of a bean, they are called papules, and may be due to 
inflammation, haemorrhage, morbid growths, etc. Discolora- 
tion of the skin has been already discussed. 

(V)i SPECIAL MORBID CONDITIONS. 

1. Haemorrhage into the skin may be divided according to 
its size and form into petechia?, small round effusions of blood, 
vibices, small longitudinal effusions, and ecchymoses, larger 
effusions. The latter are generally of traumatic origin, and 
are less interesting than the smaller effusions, which are usu- 
ally associated with the acute exanthemata, purpura hsemor- 



18 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

rhagica, etc. The most minute form of all occurs in ulcera- 
tive endocarditis, as a result of embolism of the cutaneous 
arteries, and is associated with similar haemorrhages into the 
conjunctiva and buccal mucous membrane, as well as with 
minute abscesses. To these latter we shall return later. 

2. Inflammation is met with ; — 

(a.) In small isolated spots more or less numerous. The 
affections which come under this head concern rather the 
dermatologist, and hence will receive but little attention 
here. Psoriasis represents squamous inflammation and is 
characterized by the detachment of the epidermis in small 
scales. Among the vesicular inflammations are miliaria (su- 
damina), characterized by multiple minute vesicles, either 
perfectly transparent like dew-drops, or whitish or reddish, 
presenting no trace of inflammatory action at their circum- 
ference, — and herpes (facial, progenital, zoster). In the 
latter affection the vesicles likewise contain clear fluid, but 
show evidences of inflammation at their base, and, if rup- 
tured, may be either scabbed over or remain as raw surfaces. 
The first stage of eczema (eczema vesiculosum) is also char- 
acterized by clear vesicles whose base is much inflamed, and 
swollen by collateral oedema : in their later stages they may 
become pustules or form scales and crusts. Pemphigus, with 
bullae containing either serum alone or a mixture of serum 
and pus, comes also under this head. In the form of pem- 
phigus neonatorum it is met with in new-born children and 
in the dead foetus, is most marked on the palm of the hand 
and sole of the foot, and suggests syphilis. The blisters are 
easily ruptured, and one finds there only large, round, more 
or less detached bits of epidermis and under these a moist, 
dark red, or livid surface. 

It may be questioned whether variola should not also 
come under this head, as its eruption contains at first a clear 
watery fluid, though at a later period it becomes purulent, 
and is distinguished from all those vesicles of which we have 
spoken above by being umbilicated in the centre. The pus- 
tule of variola lies between the mucous and the horny layer 



SKIN AND SUBCUTANEOUS TISSUE. 19 

of the skin and has a honey-combed character. Effusion of 
blood may take place into a small-pox vesicle as well as into 
any other, that of pemphigus, for instance. It is then called 
hemorrhagic small-pox, but the eruption is, in this case, usu- 
ally rather papular, and but little characteristic. Not only 
the contents of the vesicles of variola, especially before they 
have begun to be converted into pustules, but the underlying 
skin as well, are remarkable for the presence of micrococci, 
which are easily demonstrated in fresh sections with the 
double knife, after treatment with glacial acetic acid or dilute 
caustic alkalies. 

There are but few truly pustular eruptions (without vesic- 
ular initial stage), unless we include under this head acne 
and furuncles, which we shall treat of in connection with the 
glands and hair. Impetigo and those minute abscesses of 
embolic origin to which we alluded under Haemorrhage, con- 
stitute the class. These latter occur scattered over the 
whole body and appear as minute yellow spots, which may or 
may not be surrounded by zones of haemorrhage ; they occur 
only in connection with the malignant form of ulcerative 
endocarditis in which, as will appear later more in detail, the 
thrombi contain large nests of micrococci. If thin trans- 
verse sections be made of the skin, either fresh or rapidly 
hardened in absolute alcohol, and laid under the microscope, 
it is easy to demonstrate the presence of a vessel filled with 
micrococci in the centre of each haemorrhage or abscess. 

Papular inflammations form the last subdivision of this 
group, and include lichen, prurigo, and the papular syphilide, 
with inflammatory growth in the papillary layer. 

(5.) Erysipelas (dermatitis) and its congener phlegmon 
(cellulitis) are distinguished by their diffuseness from those 
inflammations which are met with in small circumscribed spots 
and which we have already dwelt upon. The blush which 
is so characteristic of erysipelas during life often disappears 
entirely after death, and the indications of its having existed 
resolve themselves into diffuse swelling of the skin and sub- 
cutaneous cellular tissue, and their infiltration with an opaque 



20 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

fluid rich in cells. In the early stage we see in a section 
placed under the microscope numbers of young cells, particu- 
larly along the course of the vessels, which cells later un- 
dergo fatty degeneration. Micrococci have been found in 
the lymph vessels, as well as in the contents of the vesicles 
which often spring up on erysipelatous skin. 

Since the subcutaneous cellular tissue always participates 
in the swelling and infiltration with young cells resulting 
from simple erysipelas, it can readily be seen that increase in 
the intensity of these conditions may result in purulent in- 
flammation of this tissue (cellulitis'). In this case, while the 
cutis is red and infiltrated, the subcutaneous tissue is swollen 
and its meshes are filled with opaque, yellowish, puriform or 
purulent fluid, erysipelas phleg mono sum. 

Such suppuration may, of course, occur independently of 
erysipelas, and is then often of traumatic origin. It tends to 
spread horizontally, the superficial fascia preventing its, deeper 
progress. If of long standing, the skin may be separated 
from the fascia over a large territory and a great cavity be 
formed, hanging from the walls of which, in greater or lesser 
number, bits of suppurating cellular tissue may be found. 
This is especially liable to occur if the inflammation is of 
an infective character (malignant, ichorous, gangrenous cellu- 
litis), and in consequence of it the skin may become necrotic 
from disordered nutrition. Malignant cellulitis is often the 
result of contusions which are attended with haemorrhage, 
and the contents of the cavity may thus acquire a dirty 
brownish color. The walls are often studded with fresh 
haemorrhages, and are of a dirty greenish slate color. 

3. In that form of necrosis of the skin, which we have 
just mentioned (sphacelus), the tissue is transformed into a 
soft, greasy, pulpy, dirty greenish or brownish colored mass 
(humid or moist gangrene). This is sometimes of consider- 
able extent, usually taking the form of bed-sores, so called, 
and is seated on the sacrum, the trochanters, the spinous 
processes of the vertebrae, the heels, etc. The gangrene 
which sometimes follows frost-bite, and occurs chiefly in the 



SKIN AND SUBCUTANEOUS TISSUE. 21 

feet, is of the moist variety, though, after detachment of the 
epidermis it may be eventually converted into the dry form. 
Special mention should be made of noma (cancrum oris), a 
form of gangrene of the skin of the cheeks, lips, and nose, 
which is endemic in certain places, and which is not primary 
in the skin but extends outwards from the oral mucous mem- 
brane. Microscopic examination of the opaque foul-smelling 
fluid, into which in all these cases the tissue is resolved, 
shows granular masses of detritus, quantities of fat in both 
fluid and crystalline form, needle-shaped crystals of leucine 
and tyrosine, the latter arranged in the form of sheaves, crys- 
tals of triple phosphate resembling a coffin-lid in shape, and 
numberless bacteria, of all sizes and shapes, in active motion. 
A rosy-red color is produced, according to Virchow, by the 
addition of sulphuric acid to this gangrenous fluid. 

Another form of gangrene, called dry gangrene, to distin- 
guish it from the humid variety, next claims consideration. 
This form is also called mummification, and transforms the 
skin and subcutaneous tissue into a hard, black, or brownish 
black, mass. Sometimes it also is the result of pressure, and 
then occupies the same situations which have been enume- 
rated above, but its usual seat is the ends of the lower extrem- 
ities, and its cause plugging of a large artery or some other 
disturbance of the circulation. Thus in senile gangrene a 
predisposing cause is calcification of the arterial walls and 
the resulting diminution in calibre. It is true that it is 
uncommon for these changes, and the arterial thrombosis to 
which they give rise, to result directly in gangrene ; the im- 
mediate cause is rather to be found in small peripheral 
wounds or injuries which become inflamed, and this inflam- 
mation then assumes a progressive gangrenous character. 
Secondary arterial thrombosis may supervene on this and ex- 
tend upwards toward the trunk, and may be recognized as 
secondary by the evidences of gradual progression in the 
structure of the thrombus itself. In all cases of so-called 
spontaneous gangrene, the vessels which relate to the part 
should be carefully examined. 



22 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

A form of gangrene has been described and characterized 
as white gangrene, which is a result of great distention of 
the skin, over tumors, for example, and is also sometimes 
the result of burns, the skin being transformed into a white, 
friable mass. 

Hospital gangrene (gangrama nosocomialis), a poisoned 
condition of wounds, differs from the above described forms 
of gangrene, which all have one factor in common, their de- 
pendence on disordered nutrition. Wounds affected with 
hospital gangrene present a gray, coated surface, from which 
the gray mass can be only partially removed owing to the 
fact that it is infiltrated into the tissue, — local diphtheritis. 
This gray mass consists chiefly of micrococci (minute spheri- 
cal bodies either aggregated in masses, or strung together 
like beads on a rosary, and characterized by uniformity in 
size and a peculiar lustre), and bacteria (staff-like bodies 
of various lengths, sometimes darting and wriggling about, 
sometimes strung together in chains or collected in masses, 
in which latter case they are distinguished from collections 
of micrococci by the presence of a transparent and gelati- 
nous intermediate substance in considerable amount). To 
bring out these bodies clearly it is advisable to add to the 
microscopical preparation a little dilute caustic potash, which 
dissolves most organic structures but does not affect these 
organisms. An appropriate opportunity will be taken fur- 
ther on for showing the distinction between micrococci and 
fat drops. 

4. Ulcers of the skin may be divided into simple or super- 
ficial and cavernous, and the latter class may be again divided 
into sinuous, with undermined edges, and fistulous ulcers. 
In the latter case ulceration extends in only one direction, 
forming a canal of varying width. These are usually con- 
comitants of affections of the bones and joints, and are due 
to the burrowing of pus outwards ; but they also occur 
in connection with affections of the serous cavities in the 
same way, and in both cases are called perforating fistula? 
or sinuses. If the fistula discharge one of the natural secre- 



SKIN AND SUBCUTANEOUS TISSUE. 23 

tions, it receives a special name, as lachrymal, salivary, or 
urinary fistula. With reference to the condition of the gran- 
ulations at its base an ulcer may be indolent, with feeble 
and pale granulations, or fungous, with luxuriant granu- 
lations (proud flesh). If the granulations develop rapidly 
into tough and firm connective tissue, an indurated ulcer is 
the result ; if, on the contrary, they tend to break down rap- 
idly, a suppurating, phagedenic, or gangrenous ulcer is the 
result. 

Many of the affections of the skin which we have already 
mentioned may give rise to ulceration, as indeed we specified 
in some instances ; when we come to the discussion of new 
growths in the skin, we shall find that some of them may 
also give rise to ulceration, but of a progressive character. 
A few forms still remain for discussion here, the most com- 
mon of which is the well-known chronic ulcer of the leg. 

This is a typical indolent ulcer, with thick, indurated 
edges ; its base and circumference are indurated and in a 
state of chronic inflammation, and it shows but little ten- 
dency to cicatrization. In the neighborhood of such ulcers, 
scars, resulting from antecedent ones, are often met with, 
and usually present a brownish pigmentation. The ulcers 
may be of large extent in either direction, and may, indeed, 
involve the greater part of the leg. They are prevented from 
penetrating inwards by the tibia, which is often affected with 
superficial ossifying periostitis, but it may also become more 
deeply involved in the process, and thus superficial necrosis, 
or even osteomyelitis, be produced. 

Of the remaining kinds of ulcers we shall only mention 
the varicose, which occur over dilated veins ; the gouty, which 
are the result of the rupture of gouty deposits outwards ; 
and the scorbutic, which are characterized by haemorrhage. 

5. Ulcers result in cicatrices, which sometimes are char- 
acteristic of the special process which has given rise to them. 
For example, radiating, elevated, broad scars, generally in- 
dicate an extensive burn or cauterization ; kidney-shaped, 
glossy, irregularly depressed and pigmented scars, remain 



24 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

after syphilis ; small, longitudinal, transversely striated scars 
of a silvery whiteness, occupying the deeper layers of the 
skin, and most abundant on the belly and thighs — the cica- 
trices following pregnancy — depend on rupture of bundles 
of the cutaneous connective tissue from great distention, and 
hence are not cicatrices at all, strictly speaking. The dis- 
tention is usually dependent on pregnancy, but may be due 
to ascites, anasarca, or great accumulation of fat. 

6. Apart from parasitic diseases, to which we shall come 
later, there are but few changes in the epithelial appen- 
dages of the skin, the hair and the nails, or in the glands, 
which need detain us here. 

a. Premature baldness may be dependent either on indi- 
vidual peculiarity or disease (typhoid fever, syphilis, etc.). 
Alopecia areata or vitiligo, is indicated by loss of the hair in 
round patches, and consists, strictly speaking, in a breaking 
off of the hair at the surface of the skin in consequence of a 
peculiar disturbance of nutrition. A furuncle or boil consists 
in acute purulent inflammation about, and necrosis of,, the 
hair follicles, especially those of the downy hairs. If sev- 
eral furuncles be closely aggregated — more common on the 
back than elsewhere — they form what is called a carbuncle, 
the skin over which, after the necrotic hair follicles have 
come away, is riddled and hone} T -combed. 

b. The nails may be variously distorted, in consequence 
of inflammation of the bed, especially of that portion of the 
matrix which forms the fold (paronychia), or in consequence 
of increased cellular formation in the matrix ; in this latter 
case they are thickened and incurvated (onychogryphosis), 
and appear as if raised from their bed by a laminated mass. 
Sometimes a double nail, especially on the thumb, is met 
with, and even a double terminal phalanx. 

c. The cutaneous glands, apart from new formations, pre- 
sent little of importance. The most common affection to 
which they are subject is purulent inflammation about the 
sebaceous glands, especially of the face (acne}. If this be 
associated with considerable redness and inflammatorv swell- 



SKIN AND SUBCUTANEOUS TISSUE. 25 

ing of the surrounding skin it is called acne rosacea, and is 
met with chiefly on the nose. If the inflammation start from 
the glands belonging to the hair of the beard, it is called 
acne mentagra or sycosis, but must not be confounded with 
sycosis parasitica, which depends on a vegetable growth. 

7. Morbid growths in the skin, (a.) Hypertrophy of the 
skin, involving sometimes chiefly the epidermis, sometimes 
chiefly the connective tissue, forms the connecting link be- 
tween those affections which we have considered above, and 
tumors of the skin and subcutaneous cellular tissue. Many 
of the forms of hypertrophy are of so little importance, 
and so easy of diagnosis, that their mere mention almost 
suffices. Such are : callus (tyloma), corn (clavus) — both 
mere thickenings of the epidermis. Ichthyosis, which is gen- 
erally of considerable extent, consists in increased formation 
of, and horny change in, the epidermis, and transforms the 
skin into a sort of horny coat of mail which breaks off in 
scales and plates. 

A similar, but local process, leads to the formation of 
horny excrescences (cornua cutanea). Common hard warts 
(yerrucce), which consist chiefly of epithelium, although 
they involve also increase in the papillary layer, and the so- 
called vegetations (especially common on or near the geni- 
tals), in the formation of which the papillary layer plays a 
great part, the papillae becoming very long, pointed, and 
even giving off branches, condyloma acuminata, also belong 
in this class. The epidermis does not increase enough to 
cover over all these papillary outgrowths, the result of which 
is that some of the papillae project from the surface. These 
growths sometimes are of considerable extent, particularly 
when seated at the outlet of a canal lined with mucous mem- 
brane, papilloma. 

Elephantiasis Arabum is rather an affection of the true 
skin and the subcutaneous tissue, and is chiefly met with in 
the feet, legs, and genitals. In well-marked cases the foot 
and leg are much enlarged, the angle between them is more 
or less effaced, the surface of the skin is sometimes smooth. 



26 DIA GNOSIS IN PA THOL GICAL ANA TOMY. 

sometimes studded with nodules and excrescences, and often 
pours out a secretion, which may have a milky appearance. 
The secretion is more often met with where flat superficial 
ulcers with brawny bases are present. Sometimes, especially 
on the genitals, elevations of variable size are met with, 
from which this fluid exudes in enormous quantities. On 
section cavities appear which are easily recognized as en- 
larged lymph spaces ^pachydermia lymphangiectatica'). On 
cutting into the extremities the enlargement is found to 
consist of a tough, firm, whitish tissue, which has re- 
placed the true skin and in great measure also the subcu- 
taneous tissue, and may even penetrate the intermuscular 
spaces as far as the bone (the diffuse fibroma of Virchow). 
The microscope shows a great increase in the number of ves- 
sels, and an enlargement of the papilla?, especially at the seat 
of the warty protuberances. Bundles of dense connective 
tissue cross each other in all directions, and the more com- 
plex structures which are inclosed between them, as fat, 
muscle, and nerves, are gradually destroyed ; the bone shows 
signs of extensive, irregular ossifying periostitis (hyperos- 
tosis). 

The rare affections sclerema neonatorum and scleroderma 
of adults also belong in this class. They are characterized 
by fibrous thickening of the skin, which, in its later stages, 
gives rise to atrophy and retraction of the same. The skin 
then is smooth, shiny, and so tense as to distort the joints in 
various ways. 

Soft warts or moles, when congenital, are called mother's 
marks (nozvi materni) and belong almost exclusively to the 
true skin. They are more or less sharply elevated above the 
surface of the skin ; are seen on section to consist of a soft 
gray tissue, which is strongly contrasted with the structure 
of the skin ; extend to a variable depth into the cutis, and 
sometimes even into the subcutaneous tissue ; and are cov- 
ered by an epithelial layer which is but little, if at all, 
thicker than normal. They are often pigmented, the pig- 
ment lying partly in the lower layers of epithelial cells, but 



SKIN AND SUBCUTANEOUS TISSUE. 27 

chiefly in the richly cellular connective tissue of which the 
mole is composed. These formations are interesting chiefly 
from the frequency with which sarcomatous tumors spring 
from them. 

b. Of the actual tumors which are found on the skin, 
cystic tumors (1) first demand our attention. Some of 
these are due to retention of the secretion of the hair folli- 
cles and sebaceous glands. The simplest form of these is 
the small yellow nodule, very common on the nose, called 
comedo, which on pressure allows the escape of a little yellow 
wormlike body with a black head (dirt) from the dilated 
hair follicle. This little body consists of epithelial cells and 
fat, and is merely retained secretion. Milium is a rather 
larger yellow nodule (the size of the head of a pin) ; it has 
no external opening like the comedo, which it resembles, 
however, in structure, and occupies the deeper portion of the 
hair follicle. The largest of these retention-cysts is the 
wen (^atheroma) which is ordinarily from the size of a pea to 
that of a hazel-nut, but may, in rare instances, reach the size 
of the head. Its contents consist sometimes of soft, thick, 
yellow, glistening plates of cholesterine, sometimes of a but- 
tery or even chalky mass, and are inclosed by a membrane 
of connective tissue, the cyst wall, which contains bat few 
vessels, and often has points of cretification. When of a cer- 
tain size they remain seated in the cutis, but on further 
growth encroach upon the subcutaneous tissue, and become 
entirely imbedded in it. Under the microscope the contents 
are resolved into horny epithelial cells, fatty degenerated 
cells, free fat drops, and crystallized fat, particularly choles- 
terine. 

The so-called dermoid cysts resemble wens closely, but are 
much more rare. They range from the size of a walnut to 
that of a hen's egg, and consist of a sack, containing a soft, 
yellowish, greasy mass of fat, cholesterine, epidermis, etc. 
Sometimes hair or even more organized structures are found 
in them. The wall is not, as in a wen, a simple fibrous in- 
vestment, but contains all the elements of the outer skin, — 



28 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

epidermis, cutis richly supplied with vessels, hair, and seba- 
ceous glands, which are not always distributed uniformly 
throughout the circumference but may be confined to more 
or less limited portions of it. The whole skin is thus here 
represented, and the contents are only retained sebum and 
cast-off epidermis. The formation of sebum predominates 
over that of epidermis — the reverse is the case in wens — 
and hence a large cavity containing chiefly sebum or a honey- 
like matter may nearly always be classed as a dermoid cyst 
( Virchow) . 

Other cystic formations are met with in the subcutaneous 
and intermuscular tissue, and even by the side of the bones, 
which are distinguished from those already described, in that 
they do not contain retained glandular secretion but a clear, 
highly albuminous fluid, varying in consistency from that of 
water to that of honey (meliceris). 

The Jiygromata, the most common of which is hygroma 
prsepatellare (JiousemaioV s knee'), also belong in this class, 
and are dilatated normal or newly formed bursse. They 
form ill-defined cavities in the connective tissue, sometimes 
with prolongations, and are often traversed by bands and 
septa of connective tissue, or are rough on their inner 
surface. 

Another subdivision includes those accumulations of syno- 
vial fluid in the sheaths of the tendons called ganglion, or 
weeping sinew. They are chiefly found on the wrist and 
ankle. If the secretion is thick, they are called meliceris 
cysts, or cysts with honey-like contents. Sometimes a sort 
of papillary growth takes place on the inner wall. These 
growths may become pedunculated and then detached, thus 
forming those small, flattened, grayish- white free bodies 
which are sometimes found in large numbers in these cysts. 

There is still another form of cyst which results from the 
dilatation of lymph spaces. They are commonly seated on 
the neck (Jiygromata colli), and are sometimes congenital. 

2. Vascular Tumors (Angiomata). These are very com- 
mon on the skin. We do not mean to include under this 






SKIN AND SUBCUTANEOUS TISSUE. 29 

head aneurismal dilatations of the arteries or varicosities of 
the veins, which may also cause prominence of the skin, and 
will be described under disease of the vessels, but refer here 
to dilatation, and, what is still more common, new formation 
of the capillaries (telangiectasis). These tumors project but 
little above the surface of the skin, are either bluish or 
bright red in color, are sometimes of large extent, and often 
congenital (ncevi vasculosi). Cavernous tumors, so called, are 
much less common, and depend on the new formation of 
vessels larger than capillaries ; they generally spring from 
the subcutaneous fat tissue. 

3. Lipomata (fatty tumors) are often met with on the 
skin and are to be regarded as local hyperplasia? of the sub- 
cutaneous fat tissue. They are distinctly lobulated, the 
lobules are separated by vascular connective tissue, and the 
fat cells are plainly visible to the naked eye. These tumors 
are more or less elevated above the surface, and sometimes, 
indeed, are only connected with it by a small pedicle (lipoma 
pendulum). If the interstitial connective tissue be abundant 
and dense, the tumor is harder, and white bands are seen 
running through it (lipoma fibrosum or durum) ; if the tis- 
sue softens — this is more liable to occur at the centre — 
the fat escapes from its limiting membrane, and a cavity is 
formed, filled with an oily mass. Telangiectasis is often 
associated with these tumors (lipoma telangiectodes) : this 
form is congenital. A remarkable formation of fatty tissue 
often takes place about old hernial sacs. 

A growth of mucous tissue is sometimes found in lipomata, 
especially at the centre (lipoma myxomatodes or myxoma 
lipomatodes, according as either structure predominates). 
The myxomatous portion is somewhat transparent, gelati- 
nous, and becomes white on the addition of acetic acid, as 
can be seen with the naked eye. Under the microscope — 
a bit snipped off with the scissors will generally answer the 
purpose — one sees a perfectly transparent substance, in 
which the addition of acetic acid produces a filamentous or 
granular opacity, which does not disappear on adding an ex- 



30 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

cess of the reagent, and which contains a network of star 
and spindle-shaped cells with anastomosing processes. 

4. Pure myxomata also occur, both in children (connected 
with the umbilicus) and adults. Their origin, in the latter, 
is often in the deeper tissues, and their presence in the skin 
is only secondary. 

5. The same remark applies to enchondromata, which 
generally spring from the bones or their vicinity. They 
may attain great size, may cause ulceration of the skin, and 
consequent exposure of the bluish-white cartilaginous tissue 
of which they are composed. Like the lipoma they are lobu- 
lated, and the lobules are surrounded by connective tissue. 
Sections may readily be prepared for the microscope, which 
shows their structure to be that of hyaline cartilage, except 
that sometimes, particularly near the edges of the smallest 
lobules, the cells are star-shaped (star-celled cartilage). The 
various structures of the enchondroma, the myxoma, and the 
lipoma are often combined in the same tumor. True bony 
tumors of the skin (osteomata) are very rare. 

6. Three forms of granulomata (granulationsgeschwiilste, 
Virchow) occur in the skin, the lupous, the leprous, and the 
syphilitic. 

(#.) The microscopic appearances of lupus are very varied. 
The typical form consists of multiple bluish-red nodules, 
from the size of a hemp-seed to that of a pea, springing from 
the cutis and projecting above the surface of the skin (lupus 
tuber culosus or nodosus). An earlier stage in which the 
nodules have not as yet become raised above the surface, but 
appear only as brownish-red stains, from the size of the head 
of a pin to that of a lentil, is called I. maculosus. If the 
nodules have become confluent and thus an extensive new 
formation project above the surface, it is called I. hyper- 
trophicus; if the skin over the infiltration be covered with 
epithelial scales, it is called I. exfoliativus ; and, lastly, if the 
nodules have burst and formed an ulcer or ulcers, it is called 
I. exulcerans. According to that view of the subject which 
is now prevalent, a nodular small-celled growth in the co- 






SKIN AND SUBCUTANEOUS TISSUE. 31 

rium extending outward into the papillary, as well as in- 
ward into the cellular layer, constitutes the histological base 
of these changes. Ulceration depends on a disintegration 
of these cells, and heals, leaving scars and great contraction. 
All the stages of the process (growth, ulceration, and cicatri- 
zation) may be found near each other in the same subject. 
According to Rindfleisch, lupus is to be regarded as adenoma 
of the cutaneous glands ; according to Friedlander as local 
tuberculosis. 

The name lupus erythematodes or erythematosus has been 
given to an affection which is not attended by either the 
formation of nodules or by ulceration, but by the formation 
of minute cellular masses in the cutis. This growth is very 
apt to involve the sebaceous glands (causing enlargement of 
the glands and milium), and often starts from them ; it is al- 
most strictly confined to the face, and when it extends from 
the nose symmetrically over either cheek forms a figure very 
like a butterfly. 

Lupus of long standing with its attendant cicatrices is much 
more commonly met with on the dead body than the recent 
form. The favorite seat of the disease being the face, it is 
here that its ravages are most marked ; all the prominent 
parts of the face, the tip of the nose, the lips, the eyelids, 
may be destroyed ; the skin of the face is smooth, tense, and 
glistening ; the nostrils are mere apertures in the face ; the 
mouth is transformed into a more or less rounded hole sur- 
rounded by cicatricial tissue ; the eyeballs are exposed, ulcer- 
ated, or destroyed, having been deprived of the protection of 
the lids. There is one point in regard to the distortion of the 
nose which is of special importance. Lupus attacks first the 
anterior portion (the soft parts and cartilages), while syphilis 
attacks the bone first and allows the bridge of the nose to 
sink in. 

(5.) Leprosy {elephantiasis Grcecorwii), only sporadic in 
Middle Europe, is characterized by much larger nodules, from 
the size of a hazel-nut to that of a walnut, the chief seats 
of which are the face and extremities. The nodules occupy 



32 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the corium, though they may extend into the subcutaneous 
tissue, and consist of richly cellular granulation-tissue, which, 
according to Virchow, evidently springs from the cells of 
the connective tissue. The condition of the nodules remains 
unchanged for a long time, though, when old, their cells may 
undergo fatty degeneration and thus the nodules diminish in 
size. Ulceration is* rare, and is always dependent on exter- 
nal influences. 

(c.) Syphilis may be the cause of tumor-like growths in 
the skin, as well as of more inflammatory processes (psoriasis, 
pemphigus, rupia, etc.). These growths are called gummata 
and consist of a soft, small-celled tissue with an intercellular 
substance soaked in a sticky fluid, which fluid exudes from 
the cut surface on pressure. The nodules may soften in con- 
sequence of fatty degeneration of the cells, and open ulcers 
result from the destruction of the superficial tissues. The 
base of such ulcers is formed by gummy tissue, which is con- 
stantly breaking down ; it thus acquires a yellowish, brawny 
appearance, and becomes dense and indurated to the touch. 

Many authorities class here the primary syphilitic sore, the 
so-called hard chancre, which has exactly the character we 
have just described. A second form is the mucous patch 
(condyloma latum, plaque muqueuse), which is attended by 
growth of the individual papillae, the epidermis covering 
which is thinned, softened, and moist, thus resembling that 
covering mucous membranes. A third form is ike so-called 
lupus syphiliticus, especially common on the extremities. 
In this form numerous nodules, varying in size from that of 
a hemp-seed to that of a pea, are seated in the cutis or even 
in the subcutaneous tissue ; in their early stages they are 
dense, but later they become softer (much more rapidly in 
the skin than elsewhere), and form open sores partly through 
fatty degeneration and partly through suppuration. These 
ulcers are at first round, but becoming confluent, they as- 
sume all sorts of irregular shapes, and in healing leave scars 
which are remarkable for the degree of contraction which 
they may undergo. 






SKIN AND SUBCUTANEOUS TISSUE. 33 

(c?.) Glanders or farcy (maliasmus) is also classed here 
by Virchow. This disease is attended by the formation of 
nodules in the skin which differ from those before described 
in that they tend to break down by suppuration, but like 
them consist of a small-celled growth. The nodules on 
breaking down leave ulcers which likewise, by becoming con- 
fluent, may acquire an irregular contour. There is an acute 
as well as a chronic form, the formation of nodules being 
common to both ; in the acute form more or less extensive 
cellulitis is coexistent with the nodules. 

7. Fibromata of the skin are developed either from the 
cutis or the subcutaneous tissue, are often multiple, some- 
times very dense (fibroma durum'), sometimes softer (fibroma 
molluscum). The former consist of tough dense connective 
tissue, and contain, where the formation is most recent, 
spindle and round cells. In the recent forms, the fibres of 
connective tissue are not so closely interwoven, but form a 
coarse network, the interspaces of which are occupied by a 
still finer network, which in its turn contains a quantity of 
yellowish albuminous fluid. 

That growth to which Alibert gave the name keloid, is 
also classed with the fibromata. Its most common seat is 
over the sternum, where it takes the form of divergent bands 
of fibrous tissue, elevated above the surface, and more or less 
rich in cells ; this tissue is finally transformed into a species 
of cicatrix. 

8. The sarcomata may be primary in the skin, and may 
equal the head in size ; when very large they are generally 
coarsely tabulated. They often assume the shape of a mush- 
room. The majority of them, and especially those which are 
superficial, are hard, and consist of spindle cells; but those 
which spring from the subcutaneous tissue are often composed 
of small cells. The former appear on section of a grayish or 
reddish-white color, and are either uniform or slightly striated 
in structure ; as a rule no fluid can be expressed from the cut 
surface. By teasing a small bit with needles the spindle cells 
can generally be isolated, and there is usually no difficulty in 

3 



34 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

making sections with a double knife or sharp razor, of suffi- 
cient thinness to show that the cells are united together in 
bundles which are more or less interwoven, but chiefly radiate 
outward toward the skin ; this peculiar structure can be still 
more clearly brought out by staining the specimen in methyl- 
aniline or haematoxyline. In oblique sections there is some 
danger of mistaking the transversely divided spindle cells for 
round cells, but careful examination will generally show that 
the individual roundish bodies vary in size, — according as the 
section happened to cross the middle or the extremities of 
the spindle cells, — and that the nuclei are not always dis- 
tinct but may be wholly wanting ; the latter is the case if a 
spindle cell is cut transversely near its extremity. 

These tumors sometimes spring from ulcers, — chronic 
ulcers of the leg, for instance, — as may be recognized by 
the presence of irregular brownish cicatrices of old ulcers 
in the immediate neighborhood. 

They also sometimes spring from soft warts and pigmented 
nasvi, arid then often share in the blackish or brownish pig- 
mentation of these formations. These melano-sar comas are 
usually softer than the others, consist indifferently of spindle 
or round cells, and sometimes contain spots of softening, 
which appear as cavities, with black contents, like india-ink. 
This form must be carefully distinguished from some non- 
pigmented sarcomatous growths which are very vascular, and 
in which haemorrhage often takes place (sarcoma telangiec- 
todes hwmorrhac/icum). The color of the latter is always a 
light brownish-red, and is shown by the microscope to de- 
pend on yellowish or brownish-red deposits of hsenaatoidine, 
chiefly outside of the cells ; while in the melanotic form the 
pigment is in the form of minute dark-brown or black ker- 
nels of a round or angular shape which, to some extent even 
in the softened portions, are still enclosed within the cells. 
Moreover, in the hasmorrhagic form, as a rule, the pigment 
is irregularly, in the melanotic form uniformly distributed. 
Exceptions to this rule do, however, occur, especially as 
regards the melanotic form. 



SKIN AND SUBCUTANEOUS TISSUE. 35 

The epithelial tumors now remain to be considered ; among 
these are the adenomata (hyperplasia of the cutaneous 
glands) which are very rare, unless we adopt the view of 
Rindfleisch, who regards lupus as an adenoma of the seba- 
ceous glands. 

9. True carcinomata of the skin are always secondary, 
and occur in the form of nodules from the size of a hemp- 
seed to that of a walnut. Their origin may be metastatic 
(through the blood current), or by contiguity as accessory 
nodules. The former are generally seated in the subcutane- 
ous tissue, and, as long as they remain small, the skin over 
them is freely movable ; but the latter are seated in the cutis 
and move with it. These latter are most commonly met with 
near the gland in connection with cancer of the breast, are 
often very numerous, and extend over a large surface. They 
may become confluent and transform a large extent of skin 
into a tough cancerous mass, at the periphery of which only 
isolated nodules are to be seen (cancer en cuirasse). 

The structure of a carcinoma of the skin depends on that 
of the primary growth : it may be hard — scirrhous ; or 
soft — medullary or encephaloid, mucous or colloid. The 
latter form, which is relatively rare, is peculiarly apt to 
involve large tracts of skin about the breast (in which it 
originates), and to give rise to cancer en cuirasse. 

Apart from their external appearance and manner of growth 
the carcinomata may be distinguished from other growths as 
follows : — 

The cut surface is not uniform and homogeneous, but on 
close examination is seen to present grayish-white and often 
distinct retiform bands which enclose a white or yellowish- 
white substance. An opaque and often milky fluid (cancer 
juice) can be scraped off with the knife, which the micro- 
scope shows to consist of irregular angular cells of varying 
size, with large vesiculate nuclei and large shining nucleoli 
(epithelioid cancer cells). This fluid varies greatly in quan- 
tity, and there are hard cancers from which the cells cannot 
be squeezed out, and the nature of which can only be deter- 



36 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

mined by the aid of the microscope. Sections of these show 
larger or smaller compact collections of cells without inter- 
cellular substance, in character similar to that above de- 
scribed, which are separated by septa of variable width 
consisting of connective tissue — sometimes dense, sometimes 
looser and rich in cells. The cells may be removed by firm 
brushing under water with a camel's hair pencil, and the 
stroma thus be brought to view. The diagnosis of carcinoma 
can be considered as final, only when it has been demonstrated 
that the structure consists of masses of cells more or less 
distinctly epithelioid in character and lying in alveoli with 
fibrous walls. Colloid cancer is easily recognized with the 
naked eye by the presence of masses of transparent gelat- 
inous substance which can often be readily isolated. The 
microscopic appearance of these masses is very characteristic ; 
they are enclosed in a network of connective tissue, are trans- 
parent, become opaque on the addition of acetic acid (the 
reaction of mucine), and contain a cellular detritus which has 
undergone either mucoid or fatty degeneration. 

10. The last division of malignant new growths is formed 
by the epitheliomata (cancroid, keratoid cancer of Wal- 
deyer). They occur in two different forms, and are chiefly 
found at the junction of mucous membranes with the skin, 
also on the face and scalp. The infiltrating form is the 
more common, occurring chiefly on the face ; it is seated in 
the cutis, and is elevated but little above the surface. The 
warty or papillary form implies more or less elevation above 
the surface. 

(a.) The infiltrating form may, again, be subdivided, ac- 
cording to the depth involved by the growth, into superficial 
and deep-seated epithelioma. 

Superficial epithelioma results quickly in superficial ulcer- 
ation, which may heal by cicatrization, while the growth 
extends obstinately in other directions (rodent ulcer). The 
recent new formation breaks down so rapidly that it is some- 
times difficult to recognize this form as epithelioma, and it is 
only near the edge of the ulceration, which is generally some- 






SKIN AND SUBCUTANEOUS TISSUE. 37 

what thickened and indurated, that nodules are to be found. 
Nevertheless this form, which occurs chiefly in the face, may 
make great ravages. 

The usual and typical form of epithelioma — the deep- 
seated variety — involves the skin, the subcutaneous tissue, 
and even the deeper tissues. In its early stages it appears in 
the form of a hard nodule which subsequently breaks down 
and leaves a sinuous irregular ulcer with dense everted edges 
and a hard indurated base. On the cut surface the naked 
eye can distinguish whitish plugs embedded in the tissue, 
and on pressure these plugs spring out like comedones. 
Their structure is very different from that of cancer juice ; 
they are coherent, dry, sometimes friable, and are shown by 
the microscope to consist of large, perhaps horny, cells which 
resemble those of the epidermis in all respects, and which are 
generally concentrically aggregated together in places, thus 
forming the spheroidal onion-like bodies called epithelial 
pearls or pearl globules. The whole surface is rather dry, 
like these little conical masses of cells, and it is moreover 
extremely dense, manifestly in consequence of the horny 
change which the cells have undergone. In vertical micro- 
scopic sections of the edge of the growth it is readily seen 
that all the epithelial structures of the skin — the epidermis 
proper, the hair follicles and sebaceous glands, and sometimes 
the sweat glands — take part in the new formation and thrust 
cone-shaped processes into the deeper tissues. The relation 
borne by the connective tissue into which the growth pushes 
its way, is not always the same, and even the gross appear- 
ances may be essentially modified in consequence. In some 
cases the connective tissue seems to have disappeared en- 
tirely, but in others — particularly in epithelioma of the 
lower lip, which is the most common seat of the affection — 
it may greatly predominate over the epithelial masses, so that 
difficulty in diagnosis results. Careful examination will, gen- 
erally, reveal their presence, however ill defined and scattered 
they may be. 

No tissue offers permanent resistance to the cancroid which 



38 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

increases continuously both in extent and depth. Even the 
bones may become so far involved as to break spontaneously 
(lower jaw, tibia). A cancroid never spreads by the forma- 
tion of accessory nodules in the vicinity, it is thus sharply 
distinguished from the true carcinomata. 

(5.) In the second grand division of the epitheliomata — 
the warty or papillary form — the growth of the epithelial 
cells, which takes place in the manner we have described 
above, is associated with a growth of the papillae of the skin. 
Large tumors may result from the arborescent ramifications 
of these papillae, which project above the surface, producing 
a roughened appearance, and from the resemblance thus sug- 
gested has arisen the term caulifloiver excrescence. Such a 
cauliflower look is, however, not peculiar to epitheliomata, but 
may be met with in simple hypertrophies of the skin (papil- 
loma or wart). It is only with the aid of the microscope 
that we can ascertain whether the epithelium between the 
papillae actually dips down in tongue-like processes into the 
cutis and subcutaneous tissue. The sections which are to 
decide this point, must, of course, be made vertically through 
the papillae, which are generally very long and delicate and 
contain vessels and a little fibrous tissue. It is on the gen- 
itals that these growths are chiefly met with. 

8. The only parasitic affections of the skin which we shall 
mention are those caused by vegetable parasites. 

(#.) Pityriasis versicolor is one of the most common of 
these, and is found chiefly on the chest, neck, and back, but 
rarely on the face or other portions of the body. It gives 
rise to roundish and isolated, or large irregular and confluent 
groups of brownish spots covered by scaly epidermis. The 
color as well as the scales can be removed by scratching, a 
peculiarity which distinguishes this affection from true pig- 
mentation of the deeper layers of the epidermis, chloasma. 
On putting the scales in water, under the microscope small 
rounded spores, or conidia, and perhaps a little chain-like 
mycelium (micro sp or on furfur), are seen between the epithe- 
lial cells. 



SKIN AND SUBCUTANEOUS TISSUE. 39 

(b.) The chief seat of favus is the scalp (though it does 
occur on other parts of the body), where it is found in the 
form of cup-shaped crusts, the outer layers of which are yel- 
low and brittle, the deeper whitish and firmer. These crusts 
lie in depressions in the skin and have a peculiar mouldy odor. 
On removing them the skin is found to be covered with a 
thin and shining layer of epidermis, or, it may be ulcerated 
if the affection is of long duration ; indeed, in very old cases, 
cicatrices may be found. The hairs which penetrate the crusts 
are lustreless, look as if covered with dust, and are very brit- 
tle. In the lower layers of the crusts, between the epithelial 
cells, the microscope shows the presence of a matted mycelium, 
which ramifies in all directions, and the branches of which are 
prolonged into delicate threads or ribbons, composed of elon- 
gated cells ; from these are formed elongated, oval, nucleated 
cells — spores or conidia, — which are invested with a thick, 
greenish, glistening membrane, and which form the chief 
part of the uppermost layer of the growth. In addition to 
this parasitic growth (achorion Schoenleinii), the presence of 
which gives rise to the disease in question, various adventi- 
tious spores — penicillium, aspergillus, etc. — are also found. 

(c.) Herpes tonsurans, or ring-ivorm, occurs chiefly on the 
scalp, and gives rise to circular bald spots, the skin over which 
is generally covered with a whitish granular coat of epithelial 
cells and spores. The hairs are broken off close to the skin, 
and are split at the ends. The fungus is found in the cells 
of the outer root-sheath, and of the shaft of the hair itself, as 
well as in the outer layers of the epidermis, in the form of 
a close network of mycelium composed of long ramifying 
branches which divide lengthwise into rows of short, broad, 
round or quadrangular spores (trichophyton tonsurans.') 

The development of the fungus in the beard is accom- 
panied by severe inflammation (sycosis parasitica') and nod- 
ules are formed which may ulcerate ; the hair follicles are 
also altered as in acne. 

This fungus is one of several which may give rise to disease 
of the nails (onychomycosis). They become rough, uneven, 



40 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

fissured, of a dirty yellow color, loose, brittle, and easily 
chipped ; the seat of the fungus is beneath the nails. 

9. The congenital malformations which are met with in 
the skin are mostly due to defective union between the lateral 
epidermal plates, a fissure being the result. 

Hare-lip, which may be either single or double, is the 
commonest instance of this. A fissure of the chest or of the 
sternum may also occur. The abdominal fissure, when ex- 
tensive, is associated with prolapse of the abdominal viscera 
— eventratio. 

If the cleft be in the hypogastric region the anterior wall 
of the bladder is also wanting, and the reddened mucous 
membrane of the posterior wall is exposed to view (extrover- 
sion). Such a fissure may extend downwards and involve 
the clitoris (fissura clitoridis), or be prolonged on the upper 
surface of the penis (epispadias). The latter — and in like 
manner hypospadias^ non-union on the inferior surface of the 
penis — may be met with in varying degree as independent 
malformations. 

As contrasted with fissure, occlusion remains to be men- 
tioned — atresia ani, urethras, vaginas ; microstomia, symble- 
raphon ; this condition depends, doubtless, on cicatrization 
during foetal life. 

B. INTERNAL EXAMINATION. 

The three great cavities of the body should be examined 
in their successive order from above downward. The abdom- 
inal is actually opened before" the thoracic cavity, but is exam- 
ined later. The reason for beginning with the head is, 
that the amount of blood in the brain and its membranes 
may be determined before the section of the great vessels in 
the neck. In medico-legal cases, in which a well-founded 
suspicion may be formed as to the cause of death, the rule 
is to begin with that cavity in which the suspected changes 
are to be found. The vertebral canal need be opened, in 
medico-legal, or in other cases, only when there is reason to 



SPINAL CANAL. 41 

think that important information may be gained by so doing. 
In ordinary cases, if it be desirable for any reason to examine 
the spinal cord, this should be done first of all, partly on ac- 
count of the inconvenience of turning the body oftener than 
is absolutely necessary, but chiefly in order to render the ex- 
amination of the brain and cord — organs which are so in- 
timately related physiologically — as connected as possible. 
In medico-legal cases, if it seem likely that by turning over 
the body we might essentially modify the relative position of 
parts — as might occur in the case of incised wounds, — the 
vertebral canal should be left to the last, and, generally, the 
chest and abdomen should be opened before the head. In 
examining a particular organ or part certain attributes of the 
organ or part as a whole — size, shape, color, consistency — 
should be first noted, and then its interior be laid open by an 
incision which should be as long and deep as circumstances 
allow. The points which it is of importance to note in ex- 
amining the interior of an organ or part vary according to its 
structure. In medico-legal cases it is of special importance 
to note the amount of blood in the body as a whole, as well 
as in its several parts or organs. 

I. EXAMINATION OF THE SPINAL CANAL. 

In order to reach the spinal cord a deep incision should be 
carried along the spinous processes of the vertebrae, and the 
tissues then freely dissected off from the laminae. Thus we 
are enabled to look for — 

(«.) Morbid conditions of the soft parts, and bones as far 
as exposed (in medico-legal cases fracture must be borne in 
mind). We have already discussed the changes which may 
be found in the soft parts, and general modifications of the 
vertebrae themselves will receive consideration in detail later 
on ; we are now concerned with those changes which are 
confined to the spinous processes and arches of the verte- 
brae. The chief of these is a congenital defect in the laminaa 
which have not reached the median line in their development, 
so that the spinous process and a larger or smaller portion of 



42 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the laminae are wanting. This condition may be confined 
to one, or involve several vertebrae, and is called spina bifida. 
In adults it is found only in the lumbar or sacral portion of 
the column, and is of limited extent ; in young children its 
localization is generally the same as in adults, but its extent 
is greater. A fissure of this kind in the upper portion of the 
column is commonly connected with the condition known as 
anencephalia, which will shortly demand our consideration. 
The higher degrees of spina bifida are always associated with 
gross changes in the cord and its membranes. 

Next, by means of a chisel or a rachitome, the spinous 
processes and adjoining portions of the laminae should be 
detached and removed. 

(6.) The thickness (translucency), degree of tension, color, 
and amount of blood in the exposed dura mater should now 
be noted, it should then be carefully opened by a longitudinal 
incision and the presence of any abnormal contents, especially 
fluid (cerebro-spinal fluid, pus, blood), noted. Next the con- 
dition of the posterior surface of the pia mater as to thick- 
ness, tension, color, and amount of blood should be noticed, 
and the resistance of the spinal cord estimated by drawing 
the finger along it with gentle pressure. 

The roots of the spinal nerves should next be severed on 
either side, the lower end of the cord gently removed from 
its bed with the hand, its anterior attachments divided one 
after another, and, lastly, it should be divided obliquely as 
near the occipital foramen as possible ; or simply extracted 
in case the brain has already been examined. 

Throughout all these procedures great care should be 
exercised neither to compress the cord, nor to bend it at a 
sharp angle, and, in case the cord is very soft, it is often safer 
to avoid touching it directly, but to remove it together with 
its dura. After removal, the condition of the anterior por- 
tion of the pia, the external appearance of the cord as to 
size and color, and, finally, the internal condition of both the 
white and gray portions should be noted, cross sections being 
made at frequent intervals with a sharp and thin-bladed 



SPINAL CANAL. 43 

knife, which should be dipped in water before each cut. The 
dura should then be separated from the bodies of the ver- 
tebrae, unless this has already been done, and haemorrhage, 
injury to, or disease of, the bones and intervertebral disks 
should be sought for. 

In examining the spinal cord attention is first to be directed 
to its — 

(a.) General Appearance. 

Modifications in color, especially in the columns of the 
cord, should be carefully examined into, since they may be 
simulated by inequalities in the surface of the section and 
peculiarities of illumination ; it is important for this reason 
to examine both cut surfaces, and to let the light fall upon 
them from all directions in turn. Although actual modifica- 
tions of color may be thus made out with tolerable accuracy, 
it must be remarked that it is very difficult to decide as to 
the exact significance of such modifications, and that even a 
very experienced observer may be deceived into regarding as 
normal, portions of the cord which the microscope shows to 
be diseased. Hence one should never neglect a microscopical 
examination, which is very readily made with sufficient thor- 
oughness for diagnostic purposes. It generally suffices to 
snip out a bit with scissors, tear it up with needles, and 
flatten it with a cover glass. 

(b.) Special Morbid Conditions. 

The special structural modifications of the parts enumer- 
ated above are so similar to those of the brain and its mem- 
branes that, for the sake of simplicity, we refer the reader 
to them. 

1. The spinal differs from the cerebral dura mater chiefly 
by not being at the same time enveloping membrane and 
periosteum, but only the former. Hence it is never the sub- 
ject of bone-forming or ossifying inflammation so common in 
the cerebral dura mater. Pachymeningitis interna ha?mor- 
rhagica is not nearly so frequent in the spinal as in the cere- 
bral dura; but the other forms of inflammation, both ex- 
ternal and internal, occur with nearly equal frequency in 



44 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

both. Haemorrhage is not so common, on account of the 
protected situation occupied by the cord ; but chronic in- 
ternal inflammations, attended with the formation of very 
small fibrous nodules, closely resembling tubercles, are, on 
the contrary, rather more common. These nodules may be- 
come calcified and thus form little bodies like grains of sand 
(pachymeningitis arenosa) which, when aggregated together 
in larger masses, are called psammoma. 

2. Inflammatory changes in the spinal, are similar to those 
in the cerebral pia mater ; but are, in general, less commonly 
met with. Arachnitis ossificans alone is more common in 
the spinal pia, and results in the formation of bony plates 
with smooth external, and jagged internal surfaces. The 
veins of the pia are usually more distended with blood in its 
posterior and inferior portions, in consequence of the position 
in which the body is generally laid. 

3. The cord is liable to much the same sort of affections 
as the brain, but not with the same degree of frequency ; 
this remark applies particularly to such processes as soften- 
ing, and is not to be wondered at when one considers how 
much better adapted to the establishment of collateral circu- 
lation the vessels of the cord are than those of the brain. 

Thus inflammation or myelitis, red, brown, and yellow 
softening, and haemorrhage are all found ; as are also new 
growths of all kinds, including the so-called solitary tuber- 
cles, so beautifully concentric in structure. There are, how- 
ever, a few affections which are either sufficiently common, 
or so peculiar in appearance as to call for detailed description. 

Chief among these is the anatomical lesion of locomotor 
ataxia, gray degeneration of the posterior columns of the 
cord, posterior spinal sclerosis. In well marked cases of this 
affection a gray stripe on either side of the posterior median 
fissure is visible even through the pia, and these stripes are 
usually more distinct inferiorly than superiorly (ascending 
degeneration). On section, either the whole or a portion of 
the posterior columns — generally those portions adjacent 
to the median fissure, the posterior median columns (Goll's 



SPINAL CANAL. 45 

columns) — are seen to be of a transparent gray, or rather 
brownish-gray, color ; they are hard, and depressed below 
the level of the neighboring portions. Changes are almost 
always found in the posterior roots also, which are gray (non- 
medullated) and atrophied. The microscope shows in needle 
preparations an abundance of fibrous tissue, but few medul- 
lated nerve fibres, and many of the so-called corpora amyla- 
cea — rounded little bodies concentric in structure, which be- 
come brownish on the addition of iodine, and blue on the ad- 
dition of sulphuric acid. Chronic spinal arachnitis, which, 
according to Virchow, is the excitant of the process found in 
the cord, is always associated with this affection Qmeningo- 
myelitis corticalis inter stitialis) , Disseminated gray degen- 
eration, also called insular sclerosis, disseminated sclerosis, 
ant ero -lateral sclerosis, is an affection of another nature and 
is not confined to the posterior columns, but may even occur 
in the brain. Microscopically this affection only differs from 
that before described in that it is not uniformly distributed, 
and thus the cord appears nodulated, the nodules indicating 
relatively healthy tissue. The microscope is said to show 
more signs of inflammation — thickening of the walls of the 
vessels, etc., — the absence of corpora amylacea, but a more 
active cellular growth in the neuroglia and the formation of 
granular corpuscles (llindfleisch). There is, finally, a third 
kind of degeneration — descending or secondary degenera- 
tion, so-called, — which causes discoloration of the white 
matter ; this is an atrophy of the lateral, and particularly 
of the posterior lateral, columns, and is secondary to local 
cerebral lesions. The diseased portions are rather grayish 
yellow than gray in color, are very soft, and non-transpar- 
ent. Needle preparations show, when placed under the 
microscope, numerous granular corpuscles and fatty degen- 
erated nerve fibres. The same changes are found both above 
and below those local lesions of the cord which are accom- 
panied by destruction of nerve fibres. 

There is, finally, a congenital condition, called lujdromen- 
ingocele to be mentioned, the cause of the previously de- 



46 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

scribed spina bifida. This consists in a sac of variable size, 
the wall of which is formed by the skin and the membranes 
of the cord, and is traversed by the roots of the nerves, while 
the cord itself is contained within the sac. The sac contains 
also a clear, watery fluid, and the whole affection starts from 
a collection of fluid in the network of the arachnoid. The 
usual seat of the affection is the sacral and lumbar regions, 
and it has been known to persist into adult life. When 
seated higher up it is called hydromyelocele ; it is here gener- 
ally due to dilation of the central canal, and involves com- 
plete disorganization of the cord at that place. 

n. THE CRANIAL CAVITY. 

In medico-legal cases attended with injury to the head the 
seat of such injury should always be disturbed as little as 
possible, and the best method of opening the head varies ac- 
cording to the individual peculiarity of the case in hand. 
Ordinarily, however, the best method is to carry the knife 
through the scalp in a line over the vertex from one mastoid 
process to the other ; and then to reflect the soft parts for- 
ward as far as the superciliary ridges, and backward behind 
the external occipital protuberance. (Changes in the soft 
parts have been already described.) 

The pericranium which is thus laid bare should now be ex- 
amined as to thickness, color, consistency, and continuity, and 
the periosteum should then be scraped off with a chisel or 
periosteum-scraper so as to expose the bony vault of the 
skull. The ordinary affections of periosteum and bone will 
receive but brief mention here, as they will be discussed in 
detail under Bones of the Extremities. We shall confine 
ourselves therefore chiefly to those changes which are pecul- 
iar to the skull and its periosteum. 

1. MORBID CONDITIONS OF THE PERIOSTEUM. 

The various forms of inflammation may be found (ossify- 
ing, purulent, and gummy periostitis), as also haemorrhage, 



CRANIUM. 4l1 

etc. Under the head of haemorrhage are included those col- 
lections of blood between the pericranium and the bone 
which are sometimes found in new-born children — cephal- 
hematoma neonatorum. The tumor thus formed is usually- 
limited to the region of the right parietal bone, never ex- 
tends across the sagittal suture, and after a certain lapse of 
time becomes surrounded by a bony wall — the result of os- 
sifying periostitis. Still later, small plates of bone, which 
at first have no connection with each other, make their ap- 
pearance on the more elevated portions of the tumor and thus 
the whole tumor may become encapsulated. Sometimes in- 
stead of blood the tumor contains a reddish-yellow puriform 
mass, which indicates that suppuration has taken place. 

2. EXAMINATION OF THE BONE FROM WITHOUT. 

(a.) General Appearance and Character. 

1. The size of the skull varies widely in different indi- 
viduals. Very large skulls with prominent frontal bones are 
generally associated with and caused by hydrocephalus. 

2. The form of the skull is for many reasons more impor- 
tant than its size ; though it, too, is subject to great varia- 
tions. In modern times the influence of race on the form 
of the skull has received much attention, and a heated con- 
troversy has arisen as to the relative significance of " long 
heads " and " short heads." One should never neglect, 
therefore, to measure both the transverse and longitudinal 
diameters. In a mesocephalic skull the transverse stands in 
an average ratio to the longitudinal diameter of 70-80 
to 100 ; if the transverse diameter fall short of this the 
skull is called dolichocephalic ; if it exceed this it is called 
br achy cephalic. The symmetry of the two sides of the 
skull is of greater pathological interest. Oblique asymme- 
try is called plagiocephalia. 

The chief classes into which abnormally shaped skulls 
have been divided are as follows : the platycephalic skull, 
with small vertical and large transverse diameters ; the oxy- 
cephalic, with large vertical and small transverse diameters ; 



48 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the scaphocephalies, in which the parietal bones incline to- 
ward one another like the sides of a roof ; clinocephalic, 
with saddle-like depressions in the temporal regions ; spheno- 
cephaly, with wedge-like prominence of the region of the 
great fontanel. 

3. The normal color of the external surface of the calva- 
ria is gray, or yellowish-gray (if there be much fatty marrow 
in the diploe), and but few red points are to be seen. Mor- 
bid processes in the bone or periosteum may give rise to a 
more or less uniform and pronounced reddish hue ; a circum- 
scribed lemon-yellow shade is associated with gummata, a 
dirty greenish-yellow or slaty shade with osteomyelitis, etc. 

4. The chief affection attended by modification in the con- 
sistency of the bones is craniotabes or soft occiput, in which 
the bone becomes flexible like parchment ; this is one of the 
manifestations of rickets. Sometimes the cranial bones of 
adults are more or less softened and replaced by connective 
tissue in connection with tumors, epithelioma for instance. 

The sutures should always be carefully examined on ac- 
count of the part which they play in the development of the 
skull. All the above mentioned modifications in the form of 
the cranium are dependent on premature synostosis of the 
sutures in whole or in part. A suture is to be regarded as 
existent so long as its delicate zigzag lines are visible. Con- 
trasted with premature ossification of the sutures is partial 
or complete persistence of the frontal suture, which normally 
disappears at the end of the fifth year. Small bones called 
ossa triquetra or Wormian bones are often found imbedded 
in the sutures, particularly in hydrocephalic skulls ; they are 
more common in the occipito-parietal suture than elsewhere. 
Sometimes they result from independent ossification of a 
fontanel, and are then called fontanel bones. 

The os Incae, as found in old Peruvian skulls, is due to 
separation of the tabular portion of the occipital bone by a 
suture. 

(5.) Special Morbid Conditions. 

Of the special morbid conditions to which bone is liable 



CRANIUM. 49 

there are but few which are peculiar to the skull or appear 
there in a peculiar form. Atrophy may depend on pressure, by 
tumors, etc., on the process of involution, as in senile atro- 
phy, which first takes place at the parietal eminences and 
may result in complete absorption of the bone, or in actual 
disease of the bone. In atrophy of the external surface of 
the skull the openings for the transmission of vessels assume 
greater prominence and, in consequence of this, the atrophied 
portions are indicated by red spots. 

The new formation of bone is very common and may ap- 
pear under a variety of forms, but every bony prominence 
must not be considered as a new formation, since the bone 
may also be elevated by a growth at its inner surface — a 
Pacchionian body, for instance. Even in this case a new for- 
mation of bone may be said, strictly speaking, to take place, 
new bone being deposited externally as the old bone is ab- 
sorbed from within ; bone which has reached its full develop- 
ment is non-distensible. There is an irregularly distributed 
form of external hyperostosis which is found associated with 
numerous irregularly shaped indentations of the skull and 
is nearly always of syphilitic origin ; in recent cases of this 
nature the diagnosis of syphilis is confirmed by the presence 
of masses of a soft and yellowish or gray substance between 
the hyperostoses. 

Fractures of the skull, which may be of very great im- 
portance medico-legally, can, as a rule, be better studied 
on the inner surface of the skull, for the reason that, 
whether attended with depression or not, the injury of the 
inner is greater than that of the outer table ; old fractures 
which have been entirely recovered from are sometimes 
found. When the examination of the external surface has 
been completed, 1 a circular incision should be made down to 



1 In cases in which there is no reason to expect changes in the calvaria it 
is more convenient to have the bone sawn through beforehand by an attendant ; 
but even then the points which we have enumerated above, and especially 
those which bear on the form of the skull, should be noted before the calvaria 
is removed. 

4 



50 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the bone through, the temporal muscles and other soft parts 
which still remain, from the glabella to the occipital protu- 
berance, and the bone then sawn through in this line, care 
being taken not to injure the brain. 1 A great saving in labor 
can be effected by sawing only partially through the bone 
and completing the work with the mallet and chisel. The' 
latter should then be inserted into the track of the saw, and 
a turn of the handle will generally suffice to remove the cal- 
varia entirely. Slight pathological adhesions between the 
bone and the dura, such as are chiefly met with in the frontal 
region, can often be broken up by trying to pry off the cal- 
varia from behind forward instead of from before backward ; 
but if, as is common enough, the adhesions be strong or ex- 
tensive, the calvaria and dura must be removed together. 

In order to do this the dura should be divided in the track of 
the saw, and then its attachment to the crista galli should be 
put on the stretch by drawing the frontal portion of the 
calvaria firmly backward, when it may be severed. This 
method must also be followed in children under seven years 
of age, for the reason that in them the dura still serves as 
internal periosteum and is hence firmly adherent 2 to the 
bone. The dura can then generally be torn from the bone, 
though it may be necessary to use a little force and the ex- 
amination can be continued in the usual way. In case, how- 
ever, that it cannot be torn off even then, all idea of exam- 
ining the inner surface of the bone and the outer surface of 
the dura must be given up, and the longitudinal sinus should 
then be opened. 

1 When it is desirable to avoid the chance of disfiguring the corpse this in- 
cision should be wedge-shaped, the apices of the wedge being at the base of the 
mastoid processes. The temporal fascia adhering to the calvaria should be 
united by sutures to that portion attached to the lower part of the skull. Rev. 

2 The examination of the brain can be much simplified in many cases, and 
particularly in young children, in whom the brain is normally softer than in 
adults, by the adoption of Griesinger's method, which consists in sawing through 
the bone and brain together. The injury which the brain receives thereby is 
but trifling ; often, indeed, less than when the usual method is followed. 



CRANIUM. 51 

3. EXAMINATION OF THE BONE FROM WITHIN. 

(a.) By examining the sawn edge of the calvaria informa- 
tion may be gained as to its gross thickness, as to the relative 
thickness of its several parts — outer table, diploe, inner 
table — and as to the amount of blood present. The cal- 
varia should also be examined by transmitted light in order 
to ascertain from the degree of translucency and color the 
thickness of the skull in general, and that of the diploetic 
portion in particular, as well as the amount of blood in the 
latter. Although we shall postpone the description of the 
various morbid changes which may occur in these parts till 
we come to the bones of the extremities, we must call atten- 
tion here to the importance of carefully noting the coloration 
of the diploe. A greenish-yellow or slaty discoloration of 
the diploe suggests the existence of severe inflammatory 
affections (as osteomyelitis, particularly its infective form) 
whose presence might otherwise be overlooked owing to the 
small amount of cancellated tissue present. 

(6.) The inner surface should next be examined, and its 
configuration be noted ; this may be varied by the presence 
or absence of juga cerebralia, hyperostoses, exostoses, digital 
impressions, abnormal depressions due to internal atrophy, 
etc. Depressions on either side of the longitudinal groove 
caused by the Pacchionian bodies are nearly always present ; 
these are of very subordinate importance, although the bone 
may be actually perforated. The width and depth of the 
grooves in which the meningeal arteries lie should also be 
noted ; these may be deepened by internal hyperostosis, 
though it should be remembered that their normal limit of 
variation is very wide. 

The color of the surface, which in the normal state is a 
grayish-yellow, should be carefully noted, for the reason that 
discoloration is often the sole indication of the presence of a 
morbid condition. I refer particularly to that chalky-white 
discoloration which occurs in isolated spots in the form of a 
network, and depends on the presence of osteophytes which 



52 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

are so little elevated above the surface as, otherwise, easily 
to escape detection (puerperal osteophytes of the frontal 
bone, etc.). The presence of adherent coagula on any por- 
tion of the inner surface of the skull should always awaken 
suspicion of fracture through that portion, and induce fur- 
ther careful examination. 

4. THE DURA MATER OF THE CONVEXITY FROM WITHOUT. 

(&.) The Membrane itself. 

On the removal of the calvaria the dura mater comes into 
view, and is to be examined with reference to its thick- 
ness, tension, color, and amount of blood. The thickness of 
the dura is indicated by the greater or less distinctness with 
which the veins of the pia and the convolutions are visible 
through it. The veins have a bluish color, the convolutions 
a yellowish gray, and both can, in the normal condition, be 
everywhere clearly distinguished. The degree of tension 
should always be tested near the anterior margin, for the 
reason that posteriorly the membrane is put on the stretch 
by the gravitation of the brain against it. In the usual 
position of a body (on the back), one should be able to raise 
up the membrane in a small fold near the apex of the fron- 
tal lobe ; if a pretty large fold can thus be lifted, the con- 
tents of the skull are diminished ; if no fold at all can be 
raised, they are increased (haemorrhage, hydrocephalus, tu- 
mor, abscess, etc.). The membrane is commonly gray in 
color, but grows whiter as it increases in thickness. It is 
only the larger vessels, and particularly the arteries, which 
contain blood, as a rule ; the arteries are easily recognizable 
as such by their venae comitantes. Sometimes, the smaller 
vessels also are full of blood, but the membrane is relatively 
so feebly vascular that it does not, even then, appear very 
red ; another consequence of this anatomical peculiarity is 
1 that the membrane is never reddened around recent injur- 
ies. 

Haemorrhage between the dura and the bones is called 
extrameningeal, and may be of traumatic origin, even though 



MEMBRANES OF THE BRAIN. 53 

the bone itself be intact. One of the most common affec- 
tions of the external surface of the dura, is ossifying inflam- 
mation {pachymeningitis externa ossificans), which renders 
the membrane firmly adherent; if it then be forcibly de- 
tached, fibrous shreds remain adherent here and there to the 
bone, which shreds are portions of the dura itself and are 
not to be confounded with new-formed false membranes as 
found on serous surfaces. Purulent inflammation {pachymen- 
ingitis externa purulenta) is less common on the convexity, 
and is usually dependent on injuries in which the bone may 
or may not be involved. The membrane is then thickened, 
opaque, yellowish in color, and covered with a thin film of 
pus which is never found in large quantities. 

True syphilitic inflammation ( pachymeningitis externa 
gummosa) is generally associated with similar changes in 
the bone. Recent gummata are yellowish-gray in color, and 
have a gelatinous appearance; older gummata present this 
gelatinous appearance only at their periphery and contain in 
their interior bright yellow masses of irregular form. Needle 
preparations of the recent formations show great numbers of 
round and spindle cells ; those of the old and yellow forma- 
tions contain great numbers of fatty degenerated cells and 
fatty detritus. Tubercular inflammation is rare and always 
associated with tubercular change in the adjacent bone. 

The true new formations which are met with in the dura 
will demand consideration in another place, and here I will 
only call attention to those small gray nodules consisting of 
several rounded lobules which are so often seen near the 
longitudinal sinus in a spot corresponding to the anterior 
extremity of the sagittal suture. These appear to be out- 
growths from the dura, but in reality have made their way 
through it and belong to the pia {Pacchionian bodies). 

(b.) The Longitudinal Sinus. 

The longitudinal sinus is now to be opened ; its superior 
wall should be made tense with two fingers of the left hand, 
and then be divided with the knife, the blade of which should 
be kept parallel with the surface of the membrane. Some- 



54 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

times the sinus is found empty, sometimes it contains fluid, 
or freshly coagulated blood. It may not be amiss to men- 
tion the fact that not infrequently the Pacchionian bodies 
penetrate the inferior wall of the sinus, and project into its 
cavity without causing further trouble. When the dura is 
more or less forcibly removed, they are often torn off with 
it, and one might be deceived into regarding them as por- 
tions of it ; but if the dura is carefully dissected off they re- 
tain their connection with the pia, and the former is found to 
be perforated at its points of contact with these bodies : the 
same thing may also occur on other portions of the dura. 

Occasionally the longitudinal sinus contains a more or 
less decolorized old blood clot which may be firm through- 
out or softened at its centre, and more or less adherent to 
the wall (thrombosis of the sinus'). This condition is gen- 
erally met with in children, and results from general disturb- 
ances of the circulation (marantic thrombosis) ; while throm- 
bosis of the transverse sinus is more phlebitic in nature — 
as, for instance, in caries of the petrous bone — and affects 
adults. 

5. THE DUE A MATER OF THE CONVEXITY FROM WITHIN. 

The dura of the right side should be divided near the 
sawn edge pf the bone from one extremity of the falx to the 
other, the blade of the knife being kept as nearly parallel 
with the surface as possible, and the left hand drawing the 
upper portion of the membrane away from the brain as pre- 
cautions against injuring the latter. The portion which is 
thus partially separated from its attachment should be then 
reflected over on the opposite side, so that its whole inner 
surface is exposed to view. If adhesions between the dura 
and the pia are present, they are to be divided. 

(#.) General Appearance and Character. 

The color of the inner surface is like that of the outer, 
sometimes gray, sometimes whitish. A common pathologi- 
cal condition consists in the presence of a more or less marked 
brown discoloration which may be diffused over a pretty 






MEMBRANES OF THE BRAIN. 55 

large surface or limited to smaller circumscribed patches, but 
generally occurs in the form of more or less minute specks 
(haernatoidine formed from old haemorrhage). Most of the 
modifications of color are due to blood within or without the 
vessels. The vessels of the dura in its normal condition, are 
small and form a coarse network ; whenever they are rela- 
tively large and closely interwoven, they are to be regarded 
as newly formed. Haemorrhage may occur either in the sub- 
stance of the membrane — intrameningeal — or on its inner 
surface ; in the latter situation it may vary in extent from 
the size of a point merely to that of the hand. It is always 
of great importance to decide whether the haemorrhage is free 
on the surface (inter meningeal), or whether it is separated 
from the pia by a membrane (hcematoma of the dura mater). 
In the case of small haemorrhages as well as in that of newly 
formed vessels or of brown pigmentation, it is important to 
ascertain whether they are seated in the old tissue of the 
dura or in false membranes. The character of the surface 
often throws light on this question, for the surface which nor- 
mally is smooth and reflects light, often becomes uneven and 
dull when a morbid deposit is present ; but absolute certainty 
may be attained by scraping the surface with the edge of the 
knife, which readily removes any existent deposit. 

Apart from the presence of deposits, the inner surface may 
have lost that moist glistening appearance which normally 
belongs to it, if, for any reason (haemorrhage, hydrocephalus, 
tumor, abscess), the volume of the brain be increased and 
thus pressure be exerted on the dura and its inner surface 
rendered dry. In such a case, however, the surface always 
remains smooth. Increased moisture of the surface and, es- 
pecially, the presence of free fluid on the inner surface, are 
artificial conditions, and depend on cerebro-spinal fluid which 
has escaped from an injury of the pia. 

(b.) Special Morbid Conditions. 

Of the changes which are met with on the inner surface of 
the dura the most frequent and hence the most important are 
those which are due to — 



56 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

1. Inflammation. Purulent inflammation (pachymenin- 
gitis interna purulenta) is, as on the outer surface, rare and 
gives rise to much the same appearances. So, also, ossifying 
inflammation (pachymeningitis interna ossificans), which re- 
sults in the formation of thin, irregular, and angular bits of 
bone on various parts of the dura, but particularly on the 
falx. That form of inflammation which is attended with 
fibrinous exudation, on the contrary, occurs only on the inner 
surface of the dura (pachymeningitis int. fibrinosd). Such 
exudation may later become organized and converted into a 
fibrous false membrane (pachymeningitis int. fibrosa). It 
is in this latter case that not only the above mentioned newly 
formed vessels are chiefly met with, but also haemorrhages 
(pachym. chronica int. hemorrhagica, hematoma) and pig- 
mentation (pachym. chronica int. pigmentosa), — the two lat- 
ter conditions being sequelae of and dependent on the former. 
It is a very simple matter to examine any of these conditions 
microscopically : it is only necessary to scrape off the fibrinous 
exudation or the false membrane, and spread it out under a 
covering glass with the addition of a drop of a solution of 
common salt. The membranes consist of cells and fibrous 
tissue in varying proportions, and the more abundant the cells 
are, the more recent is the membrane. The blood-vessels, 
which are often present in enormous numbers, are remarkable 
for their large caliber as contrasted with the extreme tenuity 
of their walls, which consist of little more than a layer of 
endothelium ; and thus, also, is explained their extreme lia- 
bility to rupture. If one of the brownish spots is examined 
under the microscope the discoloration is seen to depend on 
the presence of collections of reddish-brown or yellowish-red 
pigment which is generally amorphous, but may occur in the 
form of crystalline rhombic plates (hoematoidine) . 

Adhesive inflammation, which is so common in serous 
membranes, is rare in the dura, and when it does occur is 
usually of syphilitic origin — especially if the dura and pia 
be adherent over a large extent. I should not think it nec- 
essary to mention the fact that the membranes are, in their 



MEMBRANES OF THE BRAIN. 57 

normal condition, necessarily connected together where the 
veins of the pia empty into the longitudinal sinus, if I had 
not learned by experience how liable beginners are to forget 
it. It is somewhat more difficult to distinguish between 
these vessels and inflammatory adhesions which, beginning 
at some little distance from and extending as far as the 
longitudinal sinus, sometimes unite the dura and pia ; though 
error may always be avoided by carefully observing the char- 
acter and distribution of the vessels in such adhesions. 

The inner resembles the outer surface also in the rarity 
with which it is the seat of tubercular inflammation ; when 
this does occur here, it is merely an extension of the process 
and never results in the formation of relatively large cheesy 
nodules ; should these be found, they may be regarded as in 
all probability the remains of gummata. These are often 
adherent to the pia, are associated with changes in the brain 
itself, and always set up at their periphery chronic pachy- 
meningitis (fibrinous, hemorrhagic, etc.). 

2. True neoplasms of various kinds are met with in the 
dura. Sarcoma, generally the spindle-celled variety, occurs 
primarily in this situation, and may attain great size and 
perforate the bone (fungus durce matrix). Sometimes such 
a degree of inflammatory action accompanies the sarcomatous 
growth as to mask its characteristic nodules. Carcinoma, on 
the contrary, is always secondary and either metastatic or an 
extension of a process which originated elsewhere. There is 
a peculiar kind of morbid growth which is sometimes found 
and is composed entirely of large flattened cells which may 
show a concentric arrangement ; this was formerly considered 
by all authorities to be epithelioma of the dura mater; but 
of late it has received the name of endothelioma, and has 
been referred to a growth of the endothelial cells of the 
membrane. 

6. THE PIA MATER OF THE CONVEXITY. 

The next step after the examination of the right half of the 
dura is to examine that of the corresponding half of the pia. 



58 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

fa.) General Appearance and Character. 

The pia mater is a thin, colorless membrane, the propor- 
tions of which may be modified in either of two ways. Its 
network may contain fluid (blood, dropsical fluid, pus), or 
else the fibrous groundwork of the tissue may be thickened 
and appear in the form of gray or white bands. The two 
conditions — and particularly oedema and thickening — are 
very often coexistent. All these changes, with the exception 
of simple oedema, involve discoloration of the membrane, 
which becomes gray or grayish- white from fibrous thicken- 
ing ; yellow, from pus ; red, from blood, etc. Marked dry- 
ness of the surface, as in the dura, points to undue pressure 
from within. 

Before drawing any conclusions from the amount of blood 
in the pia, it is well to remember that the distribution of the 
blood is greatly influenced by the position of the body, and 
that the fullness of the large veins in the posterior portions, 
which is usually present, is chiefly hypostatic. It is a notori- 
ous fact that beginners are very apt to diagnosticate conges- 
tion when it does not exist. One should, therefore, not be 
satisfied with a general impression, but follow up particular 
vessels, and notice whether they are completely or only par- 
tially filled with blood, whether some portion or portions of 
a vessel are more full of blood than others, etc. The arteries, 
as a rule, lie in the furrows, the veins are superficial, but 
when the nature of a vessel is doubtful a solution may some- 
times be reached, in this situation as in others, by pressing 
the blood out of it and noting the nature of the larger ves- 
sels with which it communicates directly. The capillaries 
not being visible to the naked eye, capillary congestion can 
only be diagnosticated when the red spots cannot be resolved 
into a collection of delicate red lines — the finest arteries and 
veins. Thrombosis of the larger veins is secondary to throm- 
bosis of the sinus. 

(6.) Special Morbid Conditions. 

1. Hemorrhages are met with either on the surface of the 
pia (hcemorrhagioe intermeningeales), or in the tissue of the 



MEMBRANES OF THE BRAIN. 59 

pia or arachnoid itself (hcemorrhagioe arachnoidales, formerly 
called subarachnoidales). The former, as we have already 
mentioned, may come from the dura as well as the pia. That 
form of intermeningeal haemorrhage which sometimes occurs 
in new-born children from rupture of the large veins of the 
pia at their junction with the sinus, in consequence of great 
compression and overlapping of the bones of the head, is 
chiefly important from a medico-legal point of view. With 
regard to haemorrhage in general, it may be remarked that 
if the blood be coagulated one is justified in drawing the 
conclusion that the haemorrhage took place before death. 
This rule is subject to the exception that blood which was 
still fluid may coagulate during the progress of the autopsy 
if mixed with cerebro-spinal fluid. On the other hand, flu- 
idity is not positive proof that the blood escaped after death; 
especially if the blood be infiltrated within the tissue of the 
pia instead of lying free on its surface. 

2. Inflammation. The most common form of inflammation 
which is met with in the pia is arachnitis or leptomeningitis 
chronica fibrosa, and is characterized by thickening, whitish 
opacity, and, as a rule, by oedematous swelling, which latter 
is most strongly marked in the sulci where the membrane is 
thickest. The pia, when perfectly normal, lies in immediate 
contact with the convolutions and follows them into the 
sulci ; but when oedematous, its outer layer passes directly 
over the sulci from one convolution to another, and if the 
oedema be very marked may be actually separated from the 
surface of the convolutions by a layer of fluid. (Edematous 
infiltration is not always uniformly distributed, but may as- 
sume the form of large vesicles (oedema cysticum, hydrops 
multilocularis). Pacchionian bodies are, indeed, often found 
without the above mentioned signs of chronic inflammation, 
but it is in connection with these signs that they are most 
numerous and attain their largest size. They form villous, 
gray nodules which are thickly aggregated along the superior 
longitudinal fissure (though at times farther outward also), 
and are shown by the microscope to consist of papillary col- 



60 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

lections of connective tissue enveloped in a layer of endo- 
thelium. Small laminse of bone are sometimes found, but not 
so often as in the pia of the spinal cord. Virchow draws a 
distinction between superficial and deep chronic arachnitis ; 
the latter is the more important on account of its intimate 
relation with the vessels which pass from the pia into the 
cortex cerebri, and hence its tendency to set up inflammation 
in the brain tissue itself (vide meningo-encephalitis). 

Acute, more or less fibrinous, purulent inflammation 
(arachnitis suppurativa), is characterized by an infiltration 
of the tissue of the pia with fibrine and pus, which imparts 
to it a whitish-yellow, or, if, as sometimes happens, the 
inflammatory product be pure pus, a yellow discoloration. 
The favorite seat of this affection being the convexity, it is 
sometimes called meningitis of the convexity. The pus is 
chiefly collected along the larger veins in the form of yellow 
strips of variable width ; this is especialty the case in deep 
suppurative arachnitis, while in the superficial form the ves- 
sels are often completely obscured by the pus. Circum- 
scribed purulent inflammation is nearly always of traumatic 
origin. Tubercular inflammation of the convexity is rare, 
and if present has spread upward from the base in almost 
every instance. 

3. Cysticerci occur in the form of cysts from the size of a 
pea to that of a hazel-nut, as well as in the form of yellowish- 
white, fatty degenerated and cretified nodules. The cysts 
are filled with transparent watery fluid, floating in which the 
naked eye can discern a whitish body about the size of a 
hemp-seed ; this is the head of the animal, and with the aid of 
a lens the hooks and four suckers can easily be distinguished. 
Even after the animals are dead, their presence may be de- 
monstrated by tearing a portion of the nodule to pieces with 
needles, dissolving the lime salts with hydrochloric acid, and 
pressing the glass cover firmly down upon the specimen ; 
the large hooks with their strong attachments will thus be 
brought to view. Cysticerci very often cause depressions on 
the surface of the brain and sometimes complete circum- 
scribed atrophy of the cortex. 



MEMBRANES OF THE BRAIN. 61 

4. We shall postpone what we have to say about Tumors 
till we come to the consideration of the surface of the brain 
itself. 

When the examination of the right side has been completed 
a small cut should be made into a fold of the dura near 
the left anterior extremity of the falx ; the knife should 
then be held like a fiddle bow, with the ends of the thumb 
and fingers, and its point, with the cutting edge outward, is 
to be inserted into the small incision ; then, the left side of 
the dura, the left hand meanwhile drawing the membrane 
away from the brain, should be divided as far as the poste- 
rior extremity of the falx, reflected, and examined in the 
same way as on the other side. One should never neglect 
to compare the two sides, especially as to the fullness of the 
vessels. Both halves of the dura should then be firmly 
grasped in the left hand and drawn upwards and backwards 
in order to put the attachment of the falx to the crista galli 
on the stretch. The knife with its edge directed forwards 
should now be passed, parallel with and to the left of the 
falx, down to the cribriform plate of the ethmoid ; the edge 
should then be turned toward the right, and the attachment 
severed, when the knife is withdrawn, its edge being turned 
forward. By drawing the membrane firmly backward the 
veins of the pia can be cut through at their entrance into 
the sinuses, and thus the whole brain as far as the tentorium 
be laid bare. 

7. REMOVAL OF THE BRAIN FROM THE SKULL. 

In order to remove the brain the opposed fingers of the 
left hand should be introduced under the frontal lobes, these 
drawn gently backward, and the nerves which are given off 
from, as well as the vessels which go to, the base, should be 
divided one after another ; in this procedure one should cut 
from within outwards ; i. e. against the bone. When the 
tentorium is reached, beginning at its right anterior extrem- 
ity and keeping the knife close to the bone, it should be 
divided by a series of short, sawing cuts, as far back as 



62 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

possible. The same operation should then be repeated on 
the left side while the left hand gives the hemispheres sup- 
port from behind to prevent the base from being lacerated. 
Then, after severing the roots of any cranial nerves which 
may remain undivided, the knife with its edge turned to one 
side should be inserted as far as possible along the anterior 
wall into the vertebral canal, and the spinal cord be divided 
by elevating the handle of the knife. The knife should then 
be withdrawn at the side and the vertebral artery be divided 
at the same time. 1 Lastly, the knife should be reintroduced 
into the canal, but this time with its edge turned toward the 
other side, and the operation repeated. Now, the left hand 
still supporting the weight of the hemispheres from behind, 
the right hand should be so applied to the inferior surface of 
the brain that the medulla oblongata rests between the fore 
and middle fingers, and the brain may then be raised com- 
pletely from the skull. The base of the skull should be 
examined with reference to abnormal contents. 

8. THE PIA MATER AT THE BASE. 

The lateral and basal portions of the pia should now be ex- 
amined in the same manner as that of the convexity ; but 
special attention should be given to the great arteries, and 
especially the artery of the fissure of Sylvius, which should 
be examined in its whole course on account of its being the 
favorite seat of emboli, aneurisms, etc. 

(a.) Changes in the Great Vessels. 

The great vessels of the base of the brain, although of ar- 
terial nature, are characterized by the relative thinness 
of their walls ; hence any fatty or atheromatous changes 
in their intima can be readily seen from the outside, and 
are indicated by the presence of grayish, or yellowish-white 
spots of variable size and more or less diminution in the 
calibre of the vessel at the seat of the spots. The smaller 
branches opened longitudinally may be placed with the in- 

1 If the cord has already been removed it is only necessary to divide the lat- 
eral attachments of the portion which remains. 



MEMBRANES OF TEE BRAIN. 63 

tiraa upward, under the microscope, and the cells of the 
inner coat are then often seen to be transformed into an- 
gular groups of minute, refractive, dark-contoured granules 
which are altered by neither acetic acid nor dilute alkalies — 
fatty degeneration. 

Aneurismal dilatation is another morbid condition which 
is often found, and, as has already been mentioned, occurs 
with greatest frequency in the arteries of the fissures of Syl- 
vius and their branches. Such aneurisms are generally sac- 
cular, vary in size from that of a pea to that of a cherry- 
stone, but seldom exceed the latter, and generally prove fatal 
from rupture. They should always be borne in mind in cases 
of profuse haemorrhage at the base, and the vessels carefully 
examined for their presence, as this otherwise might easily 
be overlooked in a large clot. Embolism gives rise to a third 
morbid condition. The plugs are readily recognizable by 
their dryness and pale, grayish-red color, and are most fre- 
quently met with either at the origin, or at the first bifurca- 
tion of the arteries of the Sylvian fissures ; these large em- 
boli generally prove rapidly fatal, and hence are but seldom 
adherent to the wall of the vessel. 

(&.) Changes in the Pia itself. 

The most important changes which are found in the pia 
of the base are those which are due to arachnitis tuberculosa, 
and, from the fact that they are generally confined to the 
base, the disease has received the name of basilar meningitis. 
The anatomical appearances consist in the presence of col- 
lections of a yellowish, gelatinous substance of varying con- 
sistency in the network of the pia within the circle of Willis, 
and, especially, about the optic commissure ; the exudation 
may, also, extend far into the fissure of Sylvius. The diag- 
nosis is confirmed by the discovery of minute miliary tuber- 
cles which seem to follow the course of the blood-vessels, 
and are most abundant on the under surface of the frontal 
lobes or on the island of Reil. The tubercles may also be 
met with in the connective tissue of the pia apart from any 
vessels. For microscopical examination a small bit should 



64 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

be cut away from the pia, and carefully separated from the 
surface of the brain, with the aid of a stream of water, and 
then the bits of cerebral substance which still adhere to it 
are to be removed under water with a camel's-hair brush. 
The tubercles may now be seen in the walls of the vessels 
with the naked eye, and when examined in water under the 
microscope appear as round-celled fusiform swellings of the 
adventitia. The nuclei are rendered more distinct by acetic 
acid and the preparation may be readily stained. Giant cells 
are never found in these tubercles. 

Purulent arachnitis is rare at the base of the brain, though 
not so rare as the tubercular form on its convexity ; epidemic 
cerebro-spinal meningitis, however, is nearly always attended 
with the formation of pus, and is most marked at the base. 

9. EXAMINATION OF THE BRAIN EROM WITHOUT. 

When the examination of the pia of the base has been 
completed, the brain should be turned over and the pia mater 
removed, that the surface of the brain itself may be the bet- 
ter seen. The best method of removing the pia is to cut 
through the artery of the corpus callosum near the genu in 
front and over the posterior border, and then seizing the 
intermediate portion of the vessel with forceps to detach the 
membrane as carefully as possible. When the surface of the 
convexity is reached it is better to use the finger than the 
forceps; but if the pia gets torn at any place it should be 
seized with the forceps again in a sulcus, this being the sit- 
uation of the larger (arterial) vessels. In case the brain is 
very soft the hemisphere must be supported with the other 
hand, meantime, to avoid injury to the corpus callosum and 
roof of the lateral ventricle. A hint as to manipulation may 
not be out of place : with the thumb on the inner and the 
fingers on the outer surface of that portion of the pia which 
has been already detached, the brain should be gradually 
pressed away from the membrane*, from without inwards, by 
the finger tips and the dorsal surface of the last phalanges ; 
the force can thus be carefully regulated, and it is not neces- 



SURFACE OF THE BRAIN. 65 

sary to touch or soil the exposed surface of the brain. If cir- 
cumstances allow, it will be found a great assistance to let an 
attendant pour on water in a gentle stream. The pia is not 
always detached with ease, on account of more or less exten- 
sive adhesions between it and the brain, portions of which 
may remain sticking to the membrane. These adhesions are 
due to chronic inflammatory changes in the cortex (encephal- 
itis chronica corticalis*), which changes Virchow attributes to 
deep-seated chronic arachnitis, and the condition has hence 
been called meningo-encephalitis. It is in paralysis of the 
insane, so called, that this condition chiefly occurs. After 
the pia has been removed the general size and form of the 
brain can be determined (for the weight see page 75), but 
the general condition of the convolutions should receive spe- 
cial attention. The form of the convolutions is often indic- 
ative of changes in the brain itself; in general atrophy of 
the brain they are narrow and sharp on top, but they are 
broad and flattened from pressure against the calvaria, if 
from any cause the volume of the brain be increased. The 
amount of blood in the cortex as a whole is not easy to deter- 
mine from without, for the reason that the superficial vessels 
are torn out with the pia ; still, the presence of numerous 
and well-marked reddish points (pun eta vasculosa) is pretty 
clearly indicative of congestion. Sometimes more or less 
extensive portions of the surface of the pia, which normally 
is of a uniform gray tint, present a reddish or even violet 
discoloration ; such portions are particularly liable to become 
torn when the pia is removed, and are very apt to be the seat 
of the adhesions of which we have spoken above. 

Punctate as well as moderately large haemorrhages may 
be met with in any situation in consequence of injury ; 
they also occur in connection with recent inflammation, em- 
bolism of the arteries, and thrombosis of the veins second- 
ary to that of the sinus : in these two latter cases the ter- 
ritory supplied by the affected vessels is generally softened. 
True haemorrhages differ from the puncta vasculosa, the pres- 
ence of which, to a moderate extent, is physiological, in that 



66 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the blood being effused into the tissue cannot be readily- 
washed away. 

The surface of the convolutions is sometimes somewhat de- 
pressed and brownish in color (hsematoidine), in consequence 
of old injuries, and Virchow has found the ganglion cells of 
the cortex cretified in these plaques jaunes. By tearing a 
small bit of the cortex with needles, in a drop or two of 
water, and pressing lightly on the cover glass, a specimen is 
readily prepared for the microscope. The ganglion cells are, 
as a rule, recognizable from their pyramidal shape. Local, 
circumscribed lesion of the surface may also depend on 
the presence of the following tumors : tubercular nodules, 
wrongly called solitary tubercles, gummata, and sarcomata, 
the last of which are generally larger than either of the 
other two. The differential diagnosis is often very difficult, 
and sometimes impossible, or rendered possible only by the 
condition of other parts. The most distinctive characteris- 
tic of tubercle is the presence of gray submiliary tubercles in 
the grayish transparent zone which surrounds the yellow and 
cheesy centre ; these miliary tubercles are easily isolated 
with the aid of needles, and often contain enormous giant 
cells. Again, tubercles are more entirely and uniformly 
caseous than gummata, the cheesy portions of which are 
either surrounded or penetrated by more strongly marked 
zones of tissue of varying consistency. Finally, tubercles — 
the larger ones, at all events — show central softening much 
oftener than gummata, although the surrounding cerebral 
substance is more liable to softening in syphilis than in tu- 
berculosis. The distinction between sarcomatous or glio-sar- 
comatous and syphilitic growths, is often attended with the 
greatest difficulty, for the reason that the sarcomata are so 
prone to partial fatty degeneration. A tumor which is com- 
posed of a gray and transparent or tough and fibrous ground- 
work, with numerous yellow and homogeneous masses scattered 
through it, — and especially if these masses are relatively 
dense, — may, nevertheless, be regarded as of syphilitic origin. 
Needle preparations of gummy tumors in the fresh state 



INTERIOR OF THE BRAIN. 67 

show either richly cellular granulation tissue or tough cica- 
tricial connective tissue with clearly defined spindle and 
stellate cells. The yellow portions are seen to consist of a 
compact and amorphous groundwork which is here and there 
striated, and great numbers of small fat drops, but no true 
granular corpuscles are to be seen ; these, on the other hand, 
are usually very prominent in the fatty degenerated portions 
of the sarcoma, and occur isolated in the groundwork of the 
tumor. The tissue surrounding a sarcomatous growth often 
contains large and highly developed cells, but that surround- 
ing a gummy tumor does not. 

Cysticerci are also found in the cerebral tissue, and when 
in the stage of fatty degeneration and cretification might give 
rise to error in diagnosis, were it not that they are invested 
by a tough capsule of connective tissue ; their microscopical 
characteristics we have already described. 

10. EXAMINATION OF THE INTERIOR OF THE BRAIN. 

The time has now arrived for cutting into the brain, which 
should be opened in such a way as to permit the examina- 
tion of the ventricles first and then of their neighboring 
parts. 

(a.') Examination of the Ventricles of the Cerebrum. 

The brain being placed in the position which it occupies 
in the body in the erect posture, a shallow vertical incision 
should be made in the roof of the left lateral ventricle about 
one or two millimeters from the raphe of the corpus callosum 
(the incision should not be too deep lest the great ganglia 
be injured), and prolonged backwards and outwards into the 
posterior cornu as well as forwards and somewhat outwards 
into the anterior cornu. The two extremities of the cut 
should then be connected by another vertical cut outside of 
the great ganglia to the depth of the cortex of the inferior 
surface, and the left hemisphere will then be laid to one 
side like a prism which is convex on its under surface. 
The brain should then be turned round, and the right hem- 



6 8 DIA GNOSIS IN PA THOL GICAL ANA TO MY. 

isphere treated in the same manner. The lateral ventricles 
are now exposed, together with their anterior and posterior 
cornua, and are to be examined with reference to their size, 
contents (a teaspoonful at most in the normal state), and the 
condition of the ependyma. 

1. Dilatation of the ventricles, dne to an accumulation of 
clear watery fluid, but very seldom of pus, is called internal, 
or ventricular hydrocephalus, and may be either congenital 
or acquired. If the latter, it may be either of inflammatory 
or purely mechanical origin, — pressure of a tumor of the cere- 
bellum on the vena Galeni, for instance. In acquired hydro- 
cephalus the skull is rigid, and thus the brain, especially the 
white portion, becomes greatly atrophied ; in the congenital 
form, however, the skull which is still growing yields to the 
pressure of the dilated brain, and becomes larger itself. 
Abnormal openings are, indeed, sometimes thus caused in 
the skull, through which the brain may project under the 
skin : the favorite seats of this condition (hydrencephalocele) 
are the occipital regions and the lower portion of the frontal. 
These tumors do not always contain brain substance, but 
may be due also to a high degree of cystic oedema of the pia 
mater (hydromeningocele). Hydrencephalocele in its highest 
development constitutes the condition known as acrania or 
anencephalia, in which the whole bony vault of the skull is 
wanting, or else only vestiges of it remain, and sometimes 
the brain itself is in large measure destroyed by rupture of 
the surface of the tumor. Spina bifida is often coexistent 
with this condition. 

2. The normal ependyma forms a thin, smooth, colorless, 
and translucent investment of the inner walls of the ventri- 
cles, but may, pathologically, be either softened, or hardened 
and thickened. In chronic hydrocephalus it is generally 
softened, and may be separated from its attachments in the 
form of a coherent gelatinous mass. On the other hand, it 
is hardened in chronic conditions of the brain substance, at- 
tended with induration, such as sclerosis, and may resemble 
the toughest connective tissue in density (ependymitis chron- 



INTERIOR OF TEE BRAIN. 69 

tea) ; it is then usually thickened, either generally or locally, 
in the form of small nodular or warty prominences Qependy- 
mitis proliferans). These local thickenings are common 
enough in all sorts of conditions, and are usually associated 
with thickening of the pia mater ; in the lateral ventricles 
their favorite seat is along the border of the corpora striata 
at either side of the septum lucidum, but they are still more 
common in the fourth ventricle. They often appear like 
minute dew-drops, and then might be mistaken for very 
young tubercles, but they may attain the size of a hemp- 
seed, and, in rare cases, even of a pea. When torn to pieces, 
and placed in water under the microscope, they are seen to 
consist of a close network of the most delicate connective 
tissue fibres, which swell when placed in acetic acid, and 
enclose a variable number of cells, and, as a rule, great num- 
bers of corpora amylacea. The ependyma may become ad- 
herent in consequence of chronic inflammation. Such ad- 
hesions are usually only partial, and are chiefly met with in 
the posterior cornua : the peripheral portion of the cornu is 
thus shut off from the central cavity of the ventricle, and 
hydrocele of the posterior cornu results: there may be a series 
of these detached cavities. 

A rich network of large veins lies under the ependyma of 
the lateral ventricles, and these veins communicate with the 
vena magna Galeni through the velum interpositum. Small 
multiple haemorrhages are not very unfrequently found in and 
under the ependyma, especially in cases of arachnitis tuber- 
culosa. If it be desired to obtain a view of the middle or de- 
scending cornu, and the pes hippocampi, the former must be 
cut into externally to the optic thalamus. The choroid 
plexus can be easily raised from its place and examined. 
The amount of blood which it contains should be noted as 
well as the presence of any pathological conditions, the most 
common but least important of which are cysts containing 
clear fluid, and varying in size from that of a millet-seed or 
pea to that of a cherry-stone ; these are not to be mistaken 
for cysticerci, which may also be found in this situation. 



70 DIA GNOSIS IN PA TEOL GICAL ANA TOMY. 

To open the third ventricle, the corpus callosuni and the 
fornix should be severed from below upwards and the pos- 
terior portions reflected backwards ; in doing this they are 
to be raised up midway in their course, and the knife is 
to be passed into the foramen of Monro. The ventricle is 
still hidden by the velum interpositum ; the handle of the 
scalpel should be inserted under this, and it should then be 
likewise reflected from before backwards over the pineal 
gland and the corpora quadrigemina, the presence or absence 
of congestion or other morbid conditions being noted. In 
basilar meningitis, tubercles are sometimes found in the 
velum interpositum and choroid plexus, but are recognized 
with difficulty, from the fact that small papillary growths 
greatly resembling tubercles occur normally in these situa- 
tions. They can be distinguished microscopically from tuber- 
cles by placing the suspected portion on a dark colored sup- 
port of some kind ; if they are tubercles they will be seen to 
lie along the course of the vessels. The condition of the 
velum interpositum should receive special attention in all 
those cases in which abnormal contents are found in the ven- 
tricles, for the reason that effusions generally, though not 
invariably, come from the velum interpositum. The part 
played by the vena magna Galeni in those cases of hydroce- 
phalus which are due to passive congestion, has been already 
alluded to. 

(5.) The Cerebrum. 

1. Examination of the Hemispheres. 

Supporting the everted left hemisphere in the palm of the 
left hand it should be laid open by long, straight, vertical 
incisions extending to the depth of the cortex ; the little fin- 
ger, meanwhile, being kept immediately under the place 
where each incision is made, and serving by a slight upward 
movement to make the two surfaces of the cut fall apart ; 
thus all danger of injuring or soiling the parts, whether with 
knife or finger, is avoided. By taking care to make the in- 
cisions always along the upper edge of the ridges which result 
from the cuts made in the previous stage, the whole white 



INTERIOR OF THE BRAIN. 71 

substance can be thoroughly examined. The cuts should not 
be so deep as completely to sever the connection of the parts, 
but should be deep enough to expose the cortex in various 
places. The brain should then be turned round, and the 
right hemisphere treated in the same way. 

The degree of moisture of the cut surface is to be noted 
— whether glistening with the moisture of oedema, or dry, — 
as also the number and size of the red spots Qpuncta om- 
enta) where the blood-vessels have been divided. These red 
spots differ from punctiform haemorrhages in that they can- 
not be permanently washed away, while the latter can. If, 
after washing with a stream of water, the red spots reappear 
rapidly and in great numbers, considerable injection of the 
vessels of the white substance is present. It is very impor- 
tant to note the relative proportion both of one hemisphere 
to the other, and of the white and gray portions of each 
hemisphere ; but, above all, the width of the cortex should 
be noted. By noting whether the white and gray portions 
occupy the same level on the cut surface, one is greatly as- 
sisted in determining the presence of either swelling or 
atrophy of one or the other portion. The most important 
form of atrophy is that which is characterized as senile, and 
affects chiefly the cortical portion. The causes of swelling or 
enlargement are threefold: 1st. simple hyperemia, as indi- 
cated by the color of the brain, and the large size and num- 
ber of the puncta cruenta ; 2d. oedema, as indicated by ex- 
cessive moisture of the cut surfaces ; 3d. inflammatory pro- 
liferation of the neuroglia. The last form may be called 
parenchymatous enlargement, and is especially common in 
young children. It is very difficult, and sometimes even 
impossible, to distinguish the two last forms from each other. 
( Vide Encephalitis neonatorum.) 

We shall have something to say about circumscribed 
lesions at the close of our remarks on the examination of in- 
dividual portions of the brain. 

2. Examination of the Great Ganglia. 

The great ganglia, the corpora striata and optic thalami, 



72 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

may be laid open either in the direction of their fibres by in- 
cisions radiating like the sticks of a fan from the peduncle, or 
by simple transverse incisions. The latter method is better 
suited for instituting a comparison between the two sides, 
and is best carried out by cutting through corresponding 
portions of the ganglion of either side at one incision ; for 
this purpose a large thin-bladed knife should be used. In 
order to make the cut surfaces fall well apart the left hand 
should be introduced under the brain, and the tips of the 
fingers in close apposition should be placed under the por- 
tion where the incision is being made ; by then raising the 
finger tips slightly the cut is made to gape open widely. 
There is normally a lack of uniformity in the grayish shade 
of the ganglia : the corpus striatum, and particularly the 
outer zone of the nucleus lenticularis are darker and rather 
brownish in color, while the two other zones of the nucleus 
lenticularis as well as all three of the optic thalamus are 
lighter and of a more yellowish-gray. 

(c.) The Fourth Ventricle. 

In order to spare the fornix, it, together with the velum 
interpositum and the pineal gland, should be laid over to the 
left; the corpora quadrigemina are thus exposed to view, and 
may be laid open by transverse cuts. The left hand should 
then support the cerebellum from below, and an incision be 
carried along the vermiform process, remembering that the 
cavity of the ventricle lies deeper behind than in front. If 
the cut has been made exactly in the median line, the aque- 
duct of Sylvius will also be opened to view. The fourth ven- 
tricle is to be examined with reference to the same points 
as the other ventricles have been. The granular thickening 
of the ependyma, which is so often found here, has been 
already alluded to, and we should not neglect to note the 
degree of prominence of the auditory strias. 



INTERIOR OF THE BRAIN. 73 

(c?.) The Cerebellum. 

The hemispheres of the cerebellum, which have already been 
separated by the cut which opened the fourth ventricle, should 
now be further divided, one at a time, by a cut extending 
from the ventricle in the direction of the middle branch of 
the arbor vitae, and through the substance as far as the con- 
vexity; the surfaces resulting from this cut are fan-shaped, 
white at the centre, and gray at the periphery. The corpus 
dentatum is seen imbedded in the white matter, and sur- 
rounded by a delicate gray capsule. The examination of 
the cerebellum, and at the same time of the brain from 
above, is now to be completed by cuts radiating out from the 
cerebellar peduncle. 

(e.) The Pons and the Medulla Oblongata. 

It only remains to open the pons and the medulla, and to 
examine the cranial nerves. In order to do this the hemi- 
spheres should be folded together like the leaves of a book, 
thus restoring the brain to its normal shape, and then, the 
palms of the hands being placed under the sides, it should 
be turned over on its transverse axis. If it be desirable to 
investigate the condition of special vessels more minutely 
this can still easily be done, and then the size and color 
(whether grayish or not) of the nerves should be noticed ; 
finally the pons and medulla oblongata are to be cut trans- 
versely while the left hand supports them from beneath. 
In the cerebellum and in these parts, just as in the brain 
proper, the points which should receive special attention are 
the color and the amount of blood. It is advisable in all 
cases, and absolutely necessary when calcification is present, 
to dissect off the vertebral and basilar arteries from behind, 
and then lay them over forwards before cutting into the 
pons. 



74 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

(/.) Other Methods of laying open the Brain. 

It is not always necessary and may be undesirable to cut 
up the brain in the minute manner which we have laid down 
above ; especially when a local affection which can be recog- 
nized from the outside — tumor, abscess, large effusion of 
blood — is present. For the sake of the clinical interest 
which attaches to such cases the attention should be chiefly 
directed to determining the size and exact seat of the lesion, 
what portions of the brain are completely disorganized by 
the same, and what portions are only secondarily affected 
in consequence of pressure, softening, etc. The best method 
of procedure in these cases is — without removing the pia or 
making any other cut at present — to make a transverse 
cut completely across the brain and through the middle of 
the lesion with a long and thin-bladed knife, thus laying 
open the healthy as well as the diseased hemisphere, at as 
nearly the same level as possible, and securing a standard 
of comparison. A general view of the seat, extent, and na- 
ture of the lesion may thus be obtained, but, if it be de- 
sired to pursue the examination further, it will be found of 
advantage to harden the brain before doing so, for the reason 
that the diseased portions are usually so soft that the relative 
position of parts must inevitably be greatly modified if fur- 
ther incisions are made. 

Meynert's method of opening the brain is entirely differ- 
ent from that which is usually adopted, but is followed by 
many specialists in mental disease. The chief end to be 
gained by this method is the determination of the weight 
of each of the three great portions of the brain (brain-cov- 
ering, 1 brain-stem, cerebellum) taken separately. The pia 
mater is not removed, but the brain being placed with its 
base upwards, the islands of Reil 2 are dissected away from 

1 The brain-covering is composed of the cerebral lobes, olfactory nerves, 
corpus callosum, fornix, and septum lucidum. 

2 By leaving the islands of Reil attached to the brain-stem, about 24 grams, 
according to Meynert, are added to the weight of the latter. 



INTERIOR OF THE BRAIN. 75 

their attachments so freely as to allow the three fissures 
which bound each of them to be clearly seen. The pia over 
the great transverse fissure of the brain is then detached lat- 
erally and behind so that on raising the medulla oblongata, 
pons, and cerebellum, the descending cornu of the lateral 
ventricle may be directly exposed. The anterior portion of 
the parietal lobe is next grasped, drawn somewhat back- 
wards, and its connection with the stem cut through by 
keeping close to the posterior furrow of the island of Reil 
externally, and to the outer wall of the descending cornu 
internally. The island is then separated from its base by 
holding the knife nearly horizontal, and cutting through the 
outer limiting furrow, care being taken to keep close to the 
outer angle of the lateral ventricle formed by the corpus cal- 
losum and the great cerebral ganglia, which may readily be 
seen by lifting the cerebral stem. 

These cuts having been made on both sides, the knife is 
passed into the longitudinal fissure, and a horizontal section 
(parallel with the orbital surface of the frontal lobes) and 
about three centimeters deep, is made through the depression 
just in front of the anterior perforated space, then following 
the anterior furrow of the island of Reil, with a slight curve 
concave outwards until the cut previously made through the 
outer furrow is met. 

The stem and cerebellum are now raised and made tense, 
the pillars of the fornix and the septum lucidum are cut 
through from below, just in front of the anterior commissure, 
and finally the brain-stem is completely detached by sepa- 
rating from below the remaining adhesion in front of the 
corpus striatum. This portion is readily separated from the 
cerebellum by cutting through the several processes connect- 
ing the two. 

The following figures are Meynert's, and are based on the 
examination of 157 bodies at the Vienna Insane Asylum. 
The average weight of the whole brain between the ages of 
twenty and sixty-nine years, is 1,296 grams in the male, the 
maximum being in persons between forty and fifty years of 



76 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

age, and 1,169 grams in the female, the maximum being in 
those between fifty and sixty years of age. The average 
weight of the brain-covering is 1,018 grams in the male, 
917 in the female ; of the brain-stem 143 grams in the male, 
129 in the female ; of the cerebellum 135 grams in the male, 
123 in the female. 

(<7-) Morbid Conditions of the Brain. 

Of the local lesions which are met with in different por- 
tions of the brain, the first to claim our attention is, — 

1. Haemorrhage. This may be of large extent or punc- 
tate — sometimes incorrectly called capillary — though the 
two forms are very often coexistent, and the punctate va- 
riety is almost always found in the vicinity of large haemor- 
rhages. If the bleeding be of traumatic origin it is very apt 
to be seated directly opposite the point where the injury 
was inflicted (haemorrhage from contre-coup), while this point 
is absolutely or nearly free from haemorrhage. Those haemor- 
rhages which are due to disease of the vessels are found chiefly 
in the great ganglia where the arteries ascend into the brain 
from the fissure of Sylvius, and often break through into the 
lateral ventricles. Large cells filled with red blood corpus- 
cles are often found in these apoplectic clots on microscopic 
examination, and are merely white corpuscles with red ones 
incorporated in them ; they are easily found by tearing 
apart a small portion of the clot in a one per cent, solution 
of common salt, but water and acid should not be used for 
the reason that they destroy the coloring matter of the red 
cells and render them indistinct. 

2. Softening of the brain (mollities cerebri) is so often de- 
pendent on haemorrhage that it, in its various forms, comes 
naturally next in order. The form of softening which is gen- 
erally qualified as " red," results from partial breaking down 
of portions of cerebral substance between and about haemor- 
rhages, and acquires its color — which later is somewhat 
brown — from admixture with blood. Red softening may be 
of traumatic, embolic, or inflammatory origin ; and it is very 



INTERIOR OF THE BRAIN. 77 

often impossible, especially in the later stages, to arrive at the 
exact mode of origin from the local appearances alone, though 
sometimes the history of the case and the condition of other 
organs or parts throw light upon the question. If softening 
be found in the occipital lobe it is more likely to be of in- 
flammatory origin, for experience teaches us that embolism 
rarely takes place in this situation, and softening in general 
is less common in the cerebellum than in the brain proper. 

The microscope shows the softened portion to consist of 
blood, disorganized brain matter in the form of free glob- 
ules of myeline, and irregularly varicose nerve fibres. 

If the process to which the red softening is due has been 
arrested the part is generally separated from the surrounding 
healthy structures by a growth of connective tissue. The 
coloring matter of the blood is removed in part, and in part 
converted into hsematoidine, to which the brownish shade is 
due. The formed elements, which with the lapse of time 
consist largely more and more of colorless cells, undergo fatty 
degeneration, forming granular corpuscles, and, finally, a 
fatty detritus (i/ellow softening} results, which again may be 
absorbed, and, in large softenings, replaced by clear fluid. 
Thus originate the so-called apoplectic cysts, the formation 
of which requires two or three months. When the soften- 
ing is of slight extent union takes place between the walls, 
and all that remains is a little band of tough, and perhaps 
pigmented, fibrous tissue (apoplectic cicatrix). The term 
h< cyst " is not well chosen, as there is no true capsule or 
even cavity in the strict sense of the word ; but the cerebral 
substance is replaced by a delicate and vascular network of 
connective tissue, the interstices of which contain fluid and 
the remains of the cells which have become fatty degene- 
rated. If a small portion of this be laid in water under 
the microscope, there is seen a fine reticulum of connective 
tissue containing cells and greatly resembling the fibrous 
form of mucous tissue which is found in the umbilical cord 
of the foetus near the full term ; a proof that the neuroglia, 
from which this structure is developed, is closely allied to 
mucous tissue. 



78 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

Yellow softening, as has already been remarked, may be a 
later stage of the red form, but is not necessarily so, since it 
also occurs as a result of embolism, in the vicinity of tumors 
— gummata for instance — and from other causes. The ele- 
ments contained in the softened mass, especially those of the 
vessels and nerve fibres, are shown by the microscope to be 
fatty degenerated ; granular corpuscles are present in large 
numbers, and the corpora amylacea, which were mentioned 
in connection with the spinal cord, are often found. Soften- 
ing may also occur in numerous small spots which, after ab- 
sorption has taken place, assume the form of small spaces 
filled with an cedematous tissue, the so-called "porous soft- 
ening" That form of softening is of special importance 
which is found in the brain and cord of new-born children 
in numerous small and more or less whitish-yellow spots ; 
this is to be regarded as an interstitial encephalitis (en- 
cephalitis inter stitialis neonatorum) in the stage of fatty de- 
generation, and as usually dependent on syphilis (Yirchow). 

White softening is found chiefly in those portions of the 
brain which adjoin the ventricles, and like the softening of 
the ependyma of which we have already spoken, is a post- 
mortem change, and is almost always associated with inter- 
nal hydrocephalus. 

3. Inflammation of the brain has been already mentioned as 
a cause of softening, and the chief diagnostic peculiarities of 
its later stages have been described. 

The most common form of recent inflammation is the 
encephalitis inter stitialis neonatorum, to which we have al- 
ready alluded. The brain in this affection is enlarged, 
soft, sometimes much redder than normal, sometimes a pale 
grayish-yellow, and the distinction between the white and 
gray portions is more or less effaced. Specimens are readily 
prepared for the microscope by flattening out a small bit of 
the brain by means of gentle pressure on the cover glass ; 
they show, according to Virchow, an increase in the cells of 
the neuroglia, particularly in that of the white portion, where 
they are very often found in the process of conversion into 



INTERIOR OF THE BRAIN. 79 

granular corpuscles ; this degenerative process, in its later 
stages, may result in the formation of those local spots of 
softening of which we have spoken above. In adults recent 
inflammation is but seldom met with, and when it does 
occur is usually recurrent and in the neighborhood of older 
centres. It is characterized by swelling and change of con- 
sistency of the brain substance, diffuse yellowish discoloration 
(yellow oedema), and punctate haemorrhages (encephalitis 
hoemorrhagica) . 

Inflammation of the brain may also terminate in suppura- 
tion (encephalitis apostematosa), and give rise to a larger or 
smaller collection of pus, which is more apt to occupy the 
white substance ; such an abscess, when recent, is surrounded 
by brain tissue which is swollen, reddened, and contains 
haemorrhages ; but after a certain length of time (three to 
five weeks), it becomes encysted, and is then much less likely 
to cause further mischief. Cerebral pus has an acid reac- 
tion, and very often an offensive odor from chemical changes 
in the nervous tissue, although actual decomposition has not 
taken place ; the individual cells of which it is composed 
generally contain several very distinct nuclei. Whether ab- 
scesses also may undergo fatty degeneration (yellow soften- 
ing), and result in cysts, is not as yet accurately determined. 

It remains to mention the chronic forms of inflammation 
which, still more than the acute, are apt to be limited to 
small territories ; but which, on the other hand, are generally 
multiple. Spots of chronic inflammation are chiefly found in 
the white matter, and are remarkable for their gray, trans- 
parent appearance, their firmness and clearly defined edges. 
There is, however, a form of sclerosis which is found in the 
gray matter, and especially in the cortex ; it gives rise to a 
whitish discoloration with considerable induration and atro- 
phy, effacing the distinction between the white and gray por- 
tions, and is especially marked on the convolutions. This 
form is sometimes also congenital. 

That form of chronic inflammation of the cortex which 
occurs in general paralysis of the insane (encephalitis corti- 



80 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

calis, or meningo-encephalitis'), has been already mentioned 
in connection with the surface of the brain. 

4. The most important as well as most common class of 
brain tumors are the sarcomata or glio- sarcomata, which 
may be either single or multiple. They are often extremely 
vascular, and may be the seat of large or small haemorrhages, 
which are sometimes rapidly fatal. From the fact that these 
vascular tumors are also very soft, a large haemorrhage may 
readily disorganize a larger or smaller portion of the new 
formation, and one should, therefore, always carefully ex- 
amine the vicinity of haemorrhages of doubtful origin. 

The cells of these tumors, like all sarcoma cells, are very 
fragile, so that in examining fresh needle preparations, one 
often finds but little more than free nuclei ; this peculiarity 
is, indeed, so marked that Virchow, in his famous book on 
tumors, says that he classes every morbid growth in which 
he finds those free nuclei, unless otherwise controlled, as a 
sarcoma. This extreme fragility of the cells can be some- 
what obviated by the use of certain hardening fluids which 
act quickly, one of the best of which is dilute Liquor Iodin. 
Comp., — " Lugol's Solution of Iodine," — which stains the 
cells light yellow, the protoplasm being more affected than 
the nuclei. Cells which may have one or several nuclei are 
often found in these tumors, and resemble closely those many- 
armed cells of the neuroglia called spider and penicillate 
cells ; their processes are interwoven with one another, and 
thus a finely fibrillated structure is formed very similar to 
that of the neuroglia (glioma). The microscope shows us 
how haemorrhage, which is so often multiple in these tumors, 
takes place. If a small vessel be picked out of the growth 
with forceps, brushed under water with a camel's hair pencil, 
and then examined, it will be seen that its wall has under- 
gone sarcomatous change, perhaps to such a degree that it 
consists of nothing but closely aggregated sarcoma cells, and 
is thus easily ruptured. 

The brain is not a common seat for tumors of any kind, 
and the rarer forms are carcinoma (it is doubtful whether 



BASE OF THE CRANIUM. 81 

this is ever primary in the brain), psammoma, cholesteato- 
ma, melanoma, and, most rare of all, osteoma. The diagno- 
sis of carcinoma, as is well known, involves necessarily two 
things, — aggregations of epithelioid cells and an alveolar 
stroma of connective tissue. The cells may be obtained by 
simply scraping the cut surface of the growth, and their 
integrity be preserved by the addition of a dilute solution of 
iodine or of osmic acid ; while the stroma may be demon- 
strated by brushing a small bit snipped off with the scissors 
under water. A psammoma is easily recognized by its sandy 
bodies, a cholesteatoma by its pearly lustre, a melanoma 
by its color. The sandy bodies — lime salts — when placed 
under the microscope, are black by transmitted and white 
by reflected light, and are readily dissolved by hydrochloric 
acid ; the pearly lustre of the second results from delicate 
and closely aggregated glistening scales, while the cells of 
the melanoma contain brown or black pigment. The ex- 
tremely rare occurrence of gray matter within the midst of 
the white substance should also be mentioned. 

5. Finally, the cysts of animal parasites are occasionally 
found in the brain ; those of the cysticercus (already described 
in connection with the surface of the brain), are small, and 
may be either single or multiple ; while those of the echi- 
nococcus may be as large as an apple, or even larger, are 
rare and generally single. The latter, in the brain as else- 
where, are enveloped in a wall of connective tissue, within 
which is a thick, distinctly laminated, gelatinous membrane 
belonging to the animal, and presenting on its inner surface 
numbers of whitish dots — the scolices. These scolices are 
readily scraped off, and when placed in water under the 
microscope, closely resemble those of the cysticercus, except 
that the heads and hooks are smaller. The head is often 
folded into its little vesicle, but may be forced out by gentle 
pressure on the cover glass. The laminated structure of the 
membrane may be demonstrated on a thin section snipped 
off transversely with the scissors and laid in water. 



82 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 



11. THE DTJEA MATER AND BONE AT THE BASE. 

The last steps in the examination of the cranial cavity are 
the removal and inspection of the dura mater and its sinuses, 
and the inspection of the basal and lateral portions of the 
skull. What has been said with regard to the upper portion 
of the dura mater, applies also to its lower portion, except 
that purulent inflammation, not of traumatic origin, but due 
to caries, etc., as well as gummous inflammation, are more 
common here. Thrombosis of the transverse sinus is usually 
of phlebitic nature — as in caries of the petrous bone. Next 
to fractures, which are readily recognized after removal of 
the dura, and to which the attention is usually directed by 
the discovery of an effusion of blood between the dura and 
the bone, the most common lesions are those of the petrous 
bone, which is sometimes perforated in the course of caries 
of the inner ear, and thus purulent inflammation of the dura, 
or even abscess of the brain, may be set up. Myxochon- 
dromatous tumors are sometimes found on the posterior sur- 
face of the clivus Blumenbachii. 

The pituitary body is usually allowed to remain in the sella 
turcica on account of its trifling importance, but is occasion- 
ally the seat of tumors which may need careful examination. 
In this case, before removing the brain, one should cut 
through the dura on either side of the sella turcica, and 
endeavor to remove the brain and pituitary body together. 

12. THE PACE. 

When it is desirable to examine the deeper parts of the 
face, the parotid gland or the ear, the best manner of doing 
so is generally to prolong the incision which was made over 
the vertex behind the ear as far as the neck, and then to 
dissect off the integument forward after subcutaneous divis- 
ion of the external ear. 

(a.) The Parotid Gland. 

The most common affection of this gland is interstitial 
inflammation and suppuration (suppurative parotitis'), in 



THE FACE. 83 

which affection the connective tissue surrounding the lobules 
becomes infiltrated with pus, and may even be converted 
into abscesses into which the lobules project. The salivary 
glands in general and the parotid in particular, are not infre- 
quently the seat of the enchondromata or myxochondromata, 
which are recognized by their cartilaginous appearance, and 
by the presence of disseminated gelatinous spots which ac- 
quire a whitish opacity on the addition of acetic acid. 

That peculiar new formation which has received the name 
of cystosarcoma, is also found here. Its cut surface looks 
very much like a transverse section through a cabbage head, 
and the papillary growths can easily be extracted from the 
cavities which they fill out more or less completely (vide Cys- 
tosarcoma of the Breast). 

(5.) The Bones of the Face. 

If it be necessary to examine the maxillary bones also, a 
new incision must be made from behind the ear along the 
depression between the neck and the under jaw ; the reason 
for choosing this situation is to avoid any injury to the face. 

There are independent affections of the maxillary bones 
as well as those which they share in common with neighbor- 
ing parts ; we have already mentioned, for instance, that 
epithelioma of the lip sometimes involves the lower jaw. 
The independent affections are chiefly new formations of 
various kinds, and are very apt to come under the surgeon's 
knife. The most common varieties are carcinoma and fibro- 
ma, both of which are more common in the upper jaw ; 
cystoid disease, starting generally from a tooth-germ, some- 
times from a fibroma ; and sarcoma, especially giant-cell sar- 
coma, in this situation known by the name of epulis. A 
peculiarity of this latter growth is that it often becomes 
brownish in color on exposure to the air. Microscopically it 
is composed of round and spindle cells, between which enor- 
mous many-nucleated giant cells are often found : these 
can be readily isolated in needle preparations, and generally 
present numerous irregular notchos and processes of varia- 
ble size on the periphery. The above named tumors often 



84 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

spring from the antrum, which they may gradually fill out 
and distend, thus giving rise to great deformity of the face. 

Passing mention must also be made of periostitis and 
necrosis, so often met with in the lower jaws of those whose 
employment brings them in contact with phosphorus ; and of 
the inflammatory processes (periostitis) which may originate 
from the teeth, and are included under the term parulis. 

13. THE NASAL CAVITY. 

Thorough examination of the cavity of the nose is only 
possible after removal of the ethmoid bone and the parts 
which are attached to it. To do this the bone must be sawn 
through on either side of the ethmoid from the great occipi- 
tal foramen as far as the frontal bone, and then these two 
saw-tracks should be united anteriorly by a third. If only 
the mucous membrane of the anterior nares is to be exam- 
ined, this may easily be done by separating the upper lip 
from its bony attachments, and then cutting away as much 
of the cartilaginous septum and of the sides as may be de- 
sired. 

A rare but important affection, the chief seat of which is 
the mucous membrane of the nose, is glanders. This is 
characterized by inflammation which may be more or less in- 
tense and even hemorrhagic ; also by the presence of small 
uniformly yellow nodules, and ulcers with yellow, somewhat 
transparent base, and scanty secretion ; the ulcers increase in 
size and become confluent by the breaking down of nodules 
which are often present in their edges. 

Gummy formations occur both in the mucous membranes 
and the nasal bones, and by destroying the septum and the 
nasal bones may cause the nose to fall in near its root. The 
chief new formations which occur in this situation are polypi 
of the nose, so called. Some of these are due to hypertrophy 
of the mucous membrane — mucous polypi — while others 
are firm fibromata, and may arise from the base of the skull ; 
in this case they are called naso-pharyngeal polypi. 

The mucous membrane of the nose participates in many 



THE EYES. 85 

affections of the throat — diphtheritis, for instance ; but not 
in any peculiar manner. 

14. THE EYES. 

The daily increasing importance which is assumed by 
changes in the eyes, not only for their own sake, but also 
for the sake of their diagnosis during life, renders it often 
desirable to examine the retina and choroid, at least. This 
can easily be done without injuring in any way the external 
portions of the eye, by removing the roof of the orbit with 
the mallet and chisel from the inside of the skull ; the orbital 
fatty tissue and the muscles are then to be removed, and the 
globe to be drawn backwards, when the posterior half should 
be cut through with the scissors. The anterior portion of the 
globe, which is left behind, may be kept in place by plugging 
the orbit, and thus all deformity be avoided. If one does not 
happen to have a mallet and chisel at disposal, the bone 
scissors generally serve the same purpose. 

(a.) The important changes which take place in the pa- 
pilla of the retina can be seen better with the ophthalmoscope 
during life than after death, but the degree of fullness of the 
vessels, the size and number of hemorrhages, if present, and 
the presence of those white spots which are due to fatty de- 
generation of the tissue, and occur in retinitis albuminurica, 
are all easily seen in the retina after its removal. Haemor- 
rhages are almost always present in ulcerative endocarditis, 
often in chronic nephritis, basilar meningitis and other affec- 
tions of the brain. The retina is so transparent that a prelim- 
inary microscopic examination is easily made by spreading 
out a bit of it in water, or, better still, in the aqueous humor. 

(b.) The condition of the choroid which is of greatest 
interest to the practicing physician, is the presence of tuber- 
cles, which appear as small, gray nodules projecting into the 
cavity of the eyes ; they also are readily prepared for the 
microscope by simply spreading out the membrane after 
having brushed off the pigment epithelium, which, indeed, 
should be done before the microscopic examination, in order 



86 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

to avoid being deceived by small yellow spots which are due 
merely to defects in the pigment. In ulcerative endocar- 
ditis we almost always find, both in the retina and choroid, 
minute metastatic foci of inflammation which look very 
much like tubercles ; their centre is occupied by a collection 
of micrococci, which may be brought out more clearly by the 
addition of glacial acetic acid. For a description of the other 
changes which are met with in the eye, and are of less gen- 
eral interest, the reader is referred to the text books of oph- 
thalmology. 

(c.) The most important modification of the optic nerve 
is gray atrophy, which, as the name indicates, consists in a 
diminution in size, and a change from the normal white color 
to a transparent gray. The atrophy is seldom uniform, but 
the nerve is generally flattened or ribbon-like, and the degen- 
eration may be either complete or partial. As in the spinal 
cord, one may be deceived as to the color, unless great care is 
exercised. In some cases of haemorrhage at the base of the 
brain I have found effusion of blood between the nerve and 
its sheath. 

15. THE INNER EAR. 

It is but seldom that the inner ear presents conditions 
which are of interest to the general practitioner ; but if an 
examination be desired, it may be made as follows : The 
whole petrous portion should be separated from its attach- 
ments by two saw-cuts which come together in the sella 
turcica, and it may then be removed from its place, put into 
a vise, and sawn through from the posterior border of the ex- 
ternal, to the anterior or inner border of the internal, audi- 
tory canal. The internal parts are thus laid open, and the 
drum membrane left nearly intact. In the anterior portion 
may be seen the tympanic cavity and the external canal ; in 
the posterior the vestibule, the posterior wall of the tympanic 
cavity with the fenestrse, etc. The stapes is generally left 
in place, the cochlea is divided in the middle, and the anterior 
portion of the mastoid cells laid bare. An admirable view of 



THORAX AND ABDOMEN. 87 

the inner ear may be obtained by removing the roof of the 
tympanic cavity, which is easily done with either bone scis- 
sors, or mallet and chisel. 1 

Caries is almost the only affection for which it is neces- 
sary to examine the inner ear. We have already alluded to 
the disastrous effect which this affection sometimes has on the 
membranes of the brain, the brain itself, and the transverse 
sinus. Varying with the duration and intensity of the pro- 
cess, more or less extensive mischief is to be found ; such as 
perforation of the drum membrane, or enlargement of the 
tympanic cavity and vestibule, and the formation of a large 
cavity containing the ossicula freed from their attachments ; 
or a considerable portion of the bone — the cochlea, for 
instance — may have become necrotic, and more or less com- 
pletely detached by peripheral inflammation. It is in those 
who are predisposed to scrofula and tuberculosis — and above 
all in children — that these changes are generally found, 
though chronic catarrh may also result in caries ; in the lat- 
ter case the mucous membrane of the tympanic cavity, which 
normally is extremely thin, is very much thickened, covered 
with granulations, and contains masses of a dry whitish sub- 
stance (cholesteatoma, so-called) consisting of desquamated 
epithelial cells which have become cornified. 

III. THE THORACIC AND ABDOMINAL CAVITIES. 

The usual method of opening the neck and the thoracic 
and abdominal cavities is by means of a single long incision, 
extending from the chin to the symphysis pubis, and passing 
to the left of the umbilicus ; this incision should be made 
with the belly of the knife rather than the point, the latter 
being apt to penetrate too deeply and cause mischief. At 
the root of the neck, where there is generally a more or less 
deep depression, especially in thin subjects, it is well to put 
the skin on the stretch with the thumb and forefinger of the 

1 For more minute directions the reader is referred to Prof. Lucae's article, 
Klebs' Handbuch der Pathologischen Anatomic, 1,12. 



88 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

left hand. Over the thorax the incision should be made at 
once completely down to the bone, but over the abdomen 
only into the muscular layer. The right flap should then be 
grasped firmly below the ensiform cartilage, the abdominal 
wall drawn upwards, and a small incision made with care 
completely through the still undivided tissues into the peri- 
toneal cavity. In thus opening the peritoneum any escape 
of gas — as evinced by a hissing noise — or of fluid should be 
noted. Two fingers should then be introduced into the 
cavity one after the other, the wall drawn away from the 
viscera and, the fingers being spread apart like the arms of a 
V, the incision prolonged between them as far as the sym- 
physis. In order to get more space for working, it is well to 
sever subcutaneously the attachments of the recti muscles to 
the pelvis, especially if cadaveric rigidity is still present. 

In new-born children the surroundings, contents, and walls 
of the umbilical vessels are first of all to be carefully exam- 
ined. In order to do this conveniently, and at the same 
time to alter the relative position of the parts, and particu- 
larly of the arteries, as little as possible, a second cut 
should start from the main incision a little above the umbil- 
icus, pass round the other (right) side of that point, and 
join the main incision again a little below that point, thus 
separating it completely from the rest of the anterior abdom- 
inal wall. The vein and ligamentum teres can then be ex- 
amined and divided, and the arteries may afterwards be fol- 
lowed up by turning downward the flap which lies between 
the two incisions. 

The pathological conditions which are found here are chiefly 
of inflammatory origin, and occur generally in the children of 
mothers who are the subjects of puerperal disease. In um- 
bilical arteritis the walls are thickened and the vessels filled 
with a puriform mass, which is often limited by a healthy 
thrombus near the urinary bladder. Thrombophlebitis and 
periphlebitis derive their importance chiefly from their con- 
nection with the portal vein and liver, and will be treated 
more in detail in another place. 



THORAX AND ABDOMEN. «9 

First on one side and then on the other, the abdominal 
wall is now to be lifted and drawn tight over the margin of 
the ribs, and a long incision, reaching from the ensiform 
cartilage to the eleventh rib, made completely through the 
muscles. Now, with the thumb of the left hand on the cut 
surface, and the fingers on the external integument, after 
having divided the anterior attachments of the muscles, the 
soft parts are to be drawn away forcibly from the ribs and 
the submuscular tissue which is thus made tense, cut through 
in ]ong sweeping incisions. The cuts should always be made 
where the tension is greatest, and begun with the heel of 
the knife. As a general thing it is not necessary to dis- 
sect off the soft parts farther than the junction of the carti- 
laginous with the bony portions of the ribs ; but this may be 
done if it is desired to examine the mammary gland from 
behind, or if external inspection has given grounds for sus- 
pecting the presence of changes beyond this line. In the 
neck, only the superficial muscles are to be dissected off 
with the skin, and in cutting the lower attachments of the 
sterno-mastoid muscles, care is to be exercised not to injure 
the great vessels. 

I. THE SOFT PARTS. 

As in the skull, so here, the soft parts are to be first ex- 
amined. 

(a.) The thickness of the panniculus adiposus can be more 
accurately estimated now than during external inspection ; 
its color becomes deeper and sometimes orange or reddish- 
yellow, when it is the seat of atrophy. Its most important 
modifications have been already described in connection with 
the skin. 

(5.) The muscles of the neck, thorax, and abdomen are 
next to be examined, and 

1. Their General Characteristics, 
such as size, color and consistency, noted. Atrophy of the 
muscles, which may reach its highest degree on the thorax, 
has been already described; the color of healthy muscle is a 



90 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

deep red, but in anaemic and emaciated subjects it becomes 
pale, or even grayish-red, and in some diseases — typhoid 
fever, for instance — is very dark red. In typhoid fever, 
acute mania and some other affections, the muscles of the 
abdomen, in particular, sometimes present a grayish, semi- 
translucent appearance. The consistency usually stands in a 
direct ratio to the color ; pale muscles are generally flabby, 
dark muscles firm and hard. The cut surface is sometimes 
very dry and dull, — as in typhoid fever, again, — sometimes 
very moist and cedematous. 

2. Special Morbid Conditions. 

(a.) Uoemorrhage is not uncommon and may be due to 
injury, the application of cups, etc. Extensive haemorrhage 
sometimes occurs in the abdominal muscles, and particularly 
in the recti in typhoid fever (hcematoma recti abdominis). 

(b.) Those changes which reach their highest development 
in many cases of typhoid fever, and which consist sometimes 
in granular opacity and disappearance of the transverse striae 
of the muscular fibres, sometimes in that peculiar form of de- 
generation to which Zenker has given the name ivaxy, are to be 
regarded as due to parenchymatous inflammation (parenchy- 
matous myositis). As in all parenchymatous inflammations 
the granules are at first of an albuminoid nature, as is proved 
by their disappearance on the addition of dilute caustic pot- 
ash, but later are converted into fat and are unaffected by 
potash (fatty degeneration.) In waxy or hyaline degenera- 
tion, the relation of which to the fatty form is still obscure, 
the fibres are converted into a translucent substance which 
retains for a time traces of transverse striation but later be- 
comes perfectly homogeneous and presents transverse cracks. 
These cracks finally extend completely across the fibres, and 
the sheath of sarcolemma contains only isolated masses of this 
hyaline substance. Although hyaline degeneration may pro- 
duce an appearance bearing the very closest resemblance to 
that produced by amyloid degeneration, it never presents 
those reactions with iodine and aniline violet which we shall 
describe in detail in connection with amyloid degeneration in 



THORAX AND ABDOMEN. 91 

the spleen. Microscopically, the hyaline change is betrayed 
by a grayish homogeneous and transparent look, as has been 
already hinted at. To prepare for the microscope muscle, 
which is the subject of this or almost any other morbid con- 
dition, a small bit should be snipped out with scissors, par- 
allel with the course of the fibres, and should be teased with 
needles in a solution of common salt. In order to isolate the 
primitive fibres in as long strips as possible, it is well to put 
the needle points close together in the middle of the bit to 
be examined, and then to tear it completely through in oppo- 
site directions with the course of the fibres. This procedure 
should be continued till the bits become too small to allow 
further division. 

(<?.) Interstitial inflammation (interstitial myositis) may 
be either acute or chronic. The acute or purulent form may 
be either primary — when of traumatic origin it is usually so 

— or secondary and extended from neighboring parts. For 
instance, the muscles of the chest may become involved from 
the pleura, or those of the abdomen from the pelvis, in 
which latter case, as well as in the muscles of the neck after 
tracheotomy, gangrene is often superadded. This kind of 
inflammation never results in the formation of a true ab- 
scess, but rather in a purulent infiltration of the muscles, the 
separate bundles and fibres of which are ensheathed in pus, 
and are also, as a rule, the seat of either fatty or hyaline 
degeneration. Chronic interstitial inflammation, character- 
ized by increase in the interstitial connective tissue and con- 
sequent atrophy of the muscular tissue, is associated with and 
depends on all sorts of chronic changes in neighboring parts 

— affections of the ribs or of the cervical glands, pleurisy, etc. 
The muscles thus affected are firm and dense, reddish-gray 
in color, and present even to the naked eye thick fibrous 
intermuscular bands. 

(t?.) Tumors are more common in the muscles of the ex- 
tremities and will be described in that connection. 

(<?.) It is precisely in the muscles of the neck, the inter- 
costals and the diaphragm that the important parasitic mus- 



92 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

cular disease — trichinosis — has its favorite seat. In old 
eases the diagnosis is easy, the cretified capsules appearing as 
small, oval, white bodies ; and if the animals are very numer- 
ous the muscles look as if strewn with fine white sand. The 
less complete the cretification the more difficult it is to dis- 
cern the capsules, which are gray in their earlier stages, it 
is only after the formation of the capsule that the disease 
can be recognized with the naked eye, though the microscope 
will reveal its presence in muscle prepared in the manner 
which we have already described. The search may be facil- 
itated by compressing a bit of the suspected muscle between 
two glass slides and looking at it by transmitted light. In 
microscopic examination it is better to use a low power, a 
higher power being substituted if anything suspicious is 
found. Trichinae when found in muscle are smaller than 
when found in the intestines, and have a pointed head and 
a larger, rounded tail. During the first fourteen days of 
their sojourn in muscle they lie at full length within the sar- 
colemma, the contractile substance of which is broken down 
while the nuclei show signs of commencing growth ; but 
after this period the animals are coiled up spirally within 
the sarcolemma, which is considerably thickened, forming a 
fusiform dilatation. The lumen of the sarcolemma then be- 
comes gradually closed up at either end by progressive cel- 
lular growth, and the animal is finally invested in an oval 
capsule of connective tissue, which increases somewhat in 
thickness before calcification makes its appearance at the 
ends. A secondary formation of fatty tissue is often found 
on either side of old capsules which, when completely creti- 
fied, must be treated with dilute hydrochloric acid to ren- 
der the parasites themselves visible. They retain life for 
years when thus encysted. This fact may readily be demon- 
strated by opening the capsule by pressure on the cover 
glass or with needles and freeing the occupant, which may 
be distinctly seen to move ; its movements can be made 
more vigorous by warming the microscope. If it be wished 
to determine microscopically whether trichinae are present or 



THORAX AND ABDOMEN. 93 

not, it is absolutely necessary to prepare and examine a large 
number of specimens — twenty or thirty — from different 
localities, and particularly from the cervical and intercostal 
muscles and the diaphragm. The specimens should also be 
as large as is convenient, since the creatures are very irregu- 
larly distributed, being sometimes thickly aggregated in one 
place while another is entirely free from them. It is a matter 
of experience that they are most numerous near the tendons, 
and specimens should, therefore, always be taken from such 
situations if possible. The object of these investigations be- 
ing usually to determine merely the presence or absence of 
the parasite, time and labor can be saved by adopting the 
following method. Bits of muscle the size of a split pea are 
to be snipped out and coarsely teased on a glass slide in glyce- 
rine or dilute caustic alkali ; another glass slide is then to be 
laid over them, the specimens compressed between the two, 
and examined rapidly with a low power (fifty to seventy 
diameters.) 

(c.) The mammary gland may be laid open and examined 
from behind without injury to the skin. 

(a.) General Appearance. 

The size of the mammary gland in the female varies with 
the age of the individual, attaining its full development at 
the age of puberty, and becoming atrophied to a mass of 
dense and almost pure connective tissue after the menopause. 
The appearance of the gland is essentially modified during 
lactation. 

When at rest it consists chiefly of a very dense and whitish 
fibrous tissue, scattered about in which at considerable inter- 
vals grayish-red nodules of glandular tissue the size of a pin's 
head may be seen. Toward the termination of pregnancy, 
and in a still higher degree during lactation, the condition 
of things is reversed : the gland is increased in size, its gen- 
eral color is grayish-red, and its cut surface has a granular 
look which reminds one of the salivary glands, except that 
the granular masses of the breast are rather smaller. It is 
only near the nipple that much fibrous tissue is to be seen. 



94 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

Numbers of deep yellow, creamy drops exude from the cut 
surface of the gland when functionally active, either spon- 
taneously or on gentle pressure : these drops somewhat re- 
semble pus but consist solely of colostrum. The microscope 
shows innumerable fat drops, a variable number of colostrum 
corpuscles which look not unlike mulberries, on the abun- 
dance of which the intensity of the yellow color of the fluid 
depends, and granular corpuscles with smooth margins and 
distinct nuclei. 

(&.) Special Morbid Conditions. 

1. In suppurative mastitis, which is generally limited to 
circumscribed portions of the gland, the pus may be either in- 
filtrated into the connective tissue between the acini or col- 
lected in the form of abscesses. The affection is never the 
direct cause of death. Sometimes the pus is fetid, as, for 
instance, after a surgical operation in the vicinity. These 
abscesses sometimes, though rarely, dry up and leave cavities 
with cheesy contents. 

2. Chronic inflammation (chronic interstitial mastitis) is 
characterized by an increase in the connective tissue, and is 
generally confined to small portions of the gland. It may 
be associated with cystic dilatation of the milk ducts. 

3. The female breast is frequently the seat of tumors, so 
frequently that we shall describe them briefly, although they 
have generally been removed by the surgeon before the 
patient comes to the autopsy table. 

(a.) Carcinoma is the most common as well as most im- 
portant, and may be divided into three forms according to 
the relative proportion of stroma and cells. These forms 
are: hard cancer or scirrhus, soft or medullary cancer, and 
mucous or colloid cancer, which latter occupies an intermedi- 
ate position between the other two. The general characters 
of these forms both to the naked eye and microscopically 
have been already described, so we shall here confine our- 
selves to a few details. Cancer of the breast has the pecul- 
iarity that its cells (which are very small, especially in the 
scirrhous variety) are very prone to undergo fatty degen- 



THORAX AND ABDOMEN. 95 

eration ; this is shown by yellow spots, and a reticulated 
appearance, which has given rise to the term " reticulated 
cancer." The scirrhous variety rarely attains great size. 
Contraction may take place in the stroma, and thus bring 
about fatty degeneration and atrophy of the cells (atrophic 
cancer) and partial arrest of the growth. There is, in- 
deed, no well marked dividing line between the scirrhous 
and the medullary varieties. The same growth may be scir- 
rhous at its centre and medullary at its periphery ; and sec- 
ondary formations from a hard cancer may be much softer 
than the primary growth. 

Mammary cancer is generally primary and unilateral ; it 
may, however, be secondary, and has been known to be 
primary in one gland and secondary in its fellow. The out- 
ward growth of cancer, toward the skin, has been already 
described ; its inward growth, toward the pleura, as also the 
infection of the glands of the axilla, will be considered in 
another place. 

Epithelioma or cancroid is less common in the breast, 
and may originate in the external integument (pavement- 
cell cancer) or in the ducts of the glands (cylindrical-cell 
cancer). Simple hypertrophy or pure adenoma of the breast 
is properly classed under cancer, for the reason that transi- 
tion forms occupying an intermediate position between the 
two are sometimes found. This form of growth occurs gen- 
erally in the form of circumscribed nodules, the structure of 
which is precisely that of alveolar gland tissue. 

(6.) Sarcoma comes next in importance, and attains a 
large size oftener than carcinoma. Both varieties occur, the 
spindle-cell and the round-cell, and often stand in a pecul- 
iar relation to the glandular tissue. The cut surface has 
neither a homogeneous nor yet a fibrous appearance, as is 
usual in the sarcomata, but looks very like a cross section of 
a cabbage head, presenting peculiar indented lobe-like masses 
which are surrounded by fissures or clefts. Cysts which are 
otherwise scarcely appreciable can be brought to view by ex- 
tracting these masses. Sections with the double knife show 



96 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

that the more minute resembles the gross structure, in that 
wart-like or papillary growths project into and distend the 
ducts. The surface of all these growths is invested with a 
layer of cylindrical epithelium, a proliferation of that be- 
longing to the ducts. This form of cystic sarcoma or cysto- 
sarcoma proliferum is very often combined with other forms, 
and especially with mucous tissue, forming myxosarcoma. 

(<?.) Fibroma also occurs in the breast (cysto fibroma?), 
though in smaller nodules: it is easily recognized by its 
toughness and peculiar striated appearance. 

(c?.) Other tumors are rare, with the exception of hyper- 
plasia of the fatty tissue, which may be either independent 
or secondary to carcinoma, and particularly the atrophic 
form of that affection. 

The axillary lymphatic glands participate so often in 
affections of the mammary gland, and especially in the car- 
cinomatous affections, that they may be examined now as 
well as later. They are most easily reached by an incision 
in the axilla in the direction of the arm, but if one is unwil- 
ling to make a fresh incision they can be reached by dissect- 
ing the skin off still farther, particularly the skin above the 
clavicle. When they are the seat of cancer they are more 
or less enlarged, have lost their normal structure in whole 
or in part, and yield a milky fluid when compressed. 

2. INSPECTION OF THE ABDOMINAL CAVITY. 

When the examination of the soft parts has been com- 
pleted the wall should be everted on either side, and the 
contents thus exposed to view. Unless there is some special 
reason for examining these first, as in medico-legal cases in 
which it is suspected that the cause of death may be found 
in the abdominal cavity, the next step in order is to open the 
thorax. Before doing this, however, a general inspection of 
the abdomen should be made with reference to the position 
and color of the organs, especially in so far as the latter is 
dependent on congestion or its opposite — and the presence 
of any abnormal contents noted, inasmuch as the position of 



ABDOMINAL CAVITY. 97 

the organs is modified by opening the thorax, and blood or 
other fluid is liable to find its way from one cavity to the 
other. 

(a.) The Position of the Abdominal Organs. 

From the fact that the liver and the stomach are the 
organs which are most liable to undergo changes of position 
during the progress of the autopsy, they should receive 
special attention. The left border of the liver reaches nom- 
inally into the left hypochondrium, but may extend patholog- 
ically far under the left ribs and even beyond the spleen. 
The relation of the anterior border of the margin of the 
ribs is very important : it generally coincides with the mar- 
gin of the ribs, though it very often reaches two to five cen- 
timeters below this in the mamillary line. The left lobe of 
the liver usually covers up the pyloric end of the stomach 
completely. Pathological changes in the position of the 
stomach will be spoken of in connection with that organ. 

The displacements to which the intestine is subject are 
very numerous and differ greatly in importance. The coils 
of the small intestine in whole or in part, are specially lia- 
ble to displacement, being found sometimes in the pelvis 
and sometimes in either the right or left side of the abdom- 
inal cavity. The transverse colon is sometimes depressed 
in the form of a loop, which may extend even into the pel- 
vis, and the sigmoid flexure may reach to the right side of 
the abdomen, or, if the mesentery be very long indeed, to 
the liver. 

Of far more importance are hernial or ruptures, those mal- 
positions of larger or smaller portions of the intestines, and 
particularly of the small intestines, which are enclosed in 
a pouch of peritoneum. The most common form of these is 
inguinal hernia, generally divided into external or indirect, 
and internal or direct. In the former the coil of intestine 
lies in the inguinal canal, in the latter it perforates the ab- 
dominal wall. They are more simply distinguished by their 
anatomical relations to the deep epigastric artery ; the ex- 
ternal lying outside of the artery, and the internal inside 
7 



98 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

towards the median line. If the sac of an external inguinal 
hernia end within the inguinal canal, it is called hernia of 
the spermatic cord or bubonocele ; if it extend into the scro- 
tum, it is called scrotal hernia ; if the tunica vaginalis re- 
main patent so that the testicle occupies the extremity of 
the sac, it is called congenital hernia. A hernia may consist 
of intestine alone, enterocele ; of omentum alone, epiplocele ; 
or of both combined, enter o-cpiplocele. 

All the other forms of hernia are much less common. In 
femoral hernia the sac is contained within the sheath of the 
femoral vessels, and comes out below Poupart's ligament. 
We shall content ourselves with simply mentioning the ob- 
turator, ischiatic, and umbilical varieties, as well as that 
which issues through the linea alba and is called epigastric 
or hypogastric, according as it is seated above or below the 
umbilicus. In these latter varieties, and particularly in the 
umbilical, the sac may contain other organs — the liver, for 
instance. Diaphragmatic hernia, so called, is very often not 
a true hernia at all, but a mere dislocation of abdominal 
organs without a peritoneal sac into one or the other pleural 
cavity. The opening in the diaphragm is generally closed on 
the right side by the liver, a portion of which may project 
into the pleural cavity, but if the defect be on the left side, 
this cavity may contain the stomach and spleen in addition 
to coils of intestine, etc. Such defects may be either con- 
genital or the result of injury, and the former variety pos- 
sesses some medico-legal interest, from the fact that children 
who are the subjects of it generally die almost immediately 
from suffocation. 

We now come to a class of malpositions which is of very 
great importance, and not infrequently proves directly fatal ; 
we refer to twists and invaginations. Twists — the con- 
dition has received the name of volvulus — are chiefly liable 
to occur in a small intestine with a very long mesentery, and 
in the sigmoid flexure ; when they occur in the latter, not 
only is the mesentery apt to be very long, but the two arms 
of the coils are usually attached near together to the abdom- 



ABDOMINAL CAVITY. 99 

inal wall. Invagination or intussusception results when a 
portion of intestine — generally the small — becomes intro- 
verted into a lower portion — generally the large — in such 
a way that three separate layers of intestine lie one within 
another. The outer and middle layers have their mucous 
surfaces, the middle and inner their serous surfaces in appo- 
sition. The mesentery is, of course, also carried in with the 
intestine, and is thus put tightly on the stretch. In recent 
cases the invagination can be reduced by drawing on the 
mesentery, but if the condition be of some standing, reduc- 
tion is prevented by adhesions between the opposed surfaces. 
It is not every invagination which has pathological signifi- 
cance. In children it is not uncommon to find a single or 
even several invaginations, the trifling extent of which and 
the entire absence of any secondary change, even hypersemia, 
show that they must have taken place during the agony. 
Their presence shows that violent peristaltic action took 
place shortly before, and at the time of death. 

The importance of all these malpositions lies in their ten- 
dency to narrow the capacity of the intestinal canal and thus 
obstruct the passage of its contents. The same result may, 
however, ensue on some other and still rarer malpositions ; 
as, for instance, when coils of intestine become displaced into 
pouches of peritoneum within the abdominal cavity (the cav- 
ity of the lesser omentum, fossa duodeno-jejunalis, fossa sub- 
ccecalis), into holes in the great omentum or mesentery, or 
between peritonitic adhesions, etc. Whenever symptoms of 
intestinal obstruction have been present during life the intes- 
tine itself and its position must be examined minutely and 
carefully, since the seat of obstruction is often very difficult 
to find. 

In this connection we will also mention that rare condition, 
transposition of the viscera, in which the position of all the 
organs is laterally reversed. 

(6.) Color of and Amount of Blood in the Presenting 
Parts. The color depends chiefly on the amount of Mood, 
and in order that we may be enabled to inspect the whole 



100 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

small intestine from every side, it must be raised out of 
the true pelvis. This is best done as follows : the right 
hand, with its palmar surface toward the pelvic wall, should 
be introduced into the pelvis on a level with the coecum, the 
thumb, meanwhile, remaining outside to the right of the root 
of the mesentery ; the fingers are then to be passed over to 
the left side of the vertebral column between the rectum and 
intestines and the whole hand passed up the vertebrae until 
the entire mesentery lies between the thumb and fingers. 
The small intestine can then be removed from the pelvis 
and examined thoroughly' with ease. 

The most dependent coils show evidences of passive con- 
gestion in proportion to the degree of general congestion or 
anaemia. 

(c.) Abnormal Contents. 

It is necessary to remove the small intestine from the 
pelvis for the additional reason that any abnormal contents are 
most likely to be found in this part of the abdomen, though 
one must not neglect to examine the hypochondria as well. 

If abnormal contents are present their quantity is to be 
noted, and, if it seem desirable, measured. So also their color, 
pale yellow, icteric, reddish, milky, brownish, etc. ; their con- 
sistency — watery, semi-fluid, pultaceous, firm, etc. ; and their 
admixture, — clear, containing large or small flocculi, blood, 
etc. 

1. It is very important to distinguish between simple se- 
rous transudation and inflammatory, sero-fibrinous exudation. 
The presence of pus or large quantities of fibrin e point to ex- 
udation, but it is not so easy to determine the character of a 
fluid which contains small flocculi. The question is in such 
a case whether these flocculi are fibrine or only shreds of 
free endothelium such as are found also in transudations. 
Flakes of fibrine are generally larger and thicker, more or less 
opaque and grayish-white in color, while shreds of endothe- 
lium are thin, of a transparent gray color, and often are not 
distinct until the fluid is examined by transmitted light of 
moderate intensity. The microscope shows the former to 



THE ABDOMINAL CAVITY. 101 

consist of delicate fibrils which become greatly swollen on the 
addition of acetic acid, while the latter are found to consist 
of a membrane composed of closely apposed flat cells with 
large nuclei and nucleoli and perhaps large numbers of fat 
granules. 

2. Purulent exudations are of a yellow color and are fluid ; 
pyo-fibrinous exudations are yellow and soft in proportion to 
the amount of pus they contain, and usually assume the form 
of membranes covering the peritoneal surface. Fetid and 
fmcal exudations are betrayed by their odor and dirty 
brownish or gray color. The microscopical examination pre- 
sents no difficulties. In the latter form great numbers of 
bacteria or fascal matter are always found. In the exuda- 
tion of puerperal peritonitis great numbers of micrococci 
are always found, which may be joined together in the form 
of a long rosary, and the pus corpuscles are in process of 
fatty degeneration. 

3. A red color may be imparted to the fluid either by the 
blood disks or by the coloring matter of the blood. A dis- 
tinction is easily made with the microscope, but may also be 
generally made with the naked eye. Uniformity in color 
and the absence of even the smallest coagula indicate the 
coloring matter of the blood ; all the more if the color of 
the fluid does not change on standing, inasmuch as the blood 
disks always sink more or less to the bottom, which therefore 
becomes of a deeper shade than the upper portions. 

Hcemorrhage into the abdominal cavity may be inflamma- 
tory or non-inflammatory. The latter is usually the result 
of injury but may depend on other causes — spontaneous rup- 
ture of the spleen, for instance. Hemorrhagic, inflamma- 
tory exudations, on the other hand, show that inflammation 
has existed for some time or else is recurrent, and are very 
apt to be associated with tubercular and carcinomatous pro- 
cesses. 

4. When particles of undigested or semi-digested food are 
found in the abdominal cavity the greatest care should be 
used in order to determine whether an ulcerative process or 



102 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the so-called post-mortem digestion has perforated the wall of 
the stomach. 

5. Small lipomata, fibromata, and chondromata are some- 
times found as free bodies in the abdominal cavity, having 
become detached from the wall of the intestine (appendices 
epiploicse), and sometimes entozoa, particularly the lumbri- 
cus, escape through a perforation. 

Before closing these remarks on the contents of the ab- 
dominal cavity — and they apply equally to all serous cav- 
ities — we will mention the peculiar slippery feel, which 
indicates a diminished secretion from the peritoneal surface, 
resulting from disordered circulation in general and obstruc- 
tion to the venous current in particular. It is most marked 
in cholera, and is due to the presence of a large amount of 
albumen in the fluid, causing it to become frothy when inti- 
mately mixed with water. 

(c?.) Position of the Diaphragm. 

The preliminary examination of the abdominal cavity is 
closed by the determination of the position of the diaphragm. 
This is to be done by introducing the right hand, with its 
palmar surface outwards, under the margin of the ribs as far 
as the highest point of the diaphragm, the finger tips then 
being pressed against the corresponding portion of the ab- 
dominal wall. It is well always to take the measurement in 
the line of the junction of the costal cartilages with the ribs, 
if possible, for the sake of a standard of comparison. The 
normal position of the highest point of the diaphragm in 
this line on the right side, on account of the presence of the 
liver, will be found at the fourth rib, or the fourth intercos- 
tal space, while on the left side it is at the fifth rib. If the 
contents of the abdomen are greatly increased in volume, 
the vault of the diaphragm may rise as high as the second 
rib or even higher, and on the contrary an increase in the 
thoracic contents may depress the diaphragm more or less, 
and even invert it. It cannot always be determined with 
absolute certainty whether the low position of the diaphragm 
is due to enlargement of the lungs or to abnormal accumu- 



THE THORACIC CAVITY. 103 

lations in the pleural cavity, though if fluctuation can be ob- 
tained fluid must be present. Depression of the diaphragm 
when due to diseases of the heart or pericardium is generally 
more or less local. 

In new-born children who have never breathed, the usual 
position of the diaphragm is at the fourth rib on the right 
side and the fifth rib or fourth intercostal space on the left ; 
if respiration, however, has taken place it is at the fifth or 
sixth rib on the right and the sixth on the left. 



(A.) THE THORACIC CAVITY. 
Before the chest is opened it should be inspected from the 
outside. 

1. INSPECTION OF THE THORAX. 

(a.) Enlargement may be brought about by many different 
affections, and may be general, unilateral, or circumscribed. 
General enlargement is found in emphysema, and unilateral 
enlargement may depend on an accumulation of fluid alone, 
or of fluid and air together. The chest may undergo a general 
diminution in size, on the other hand, in chronic phthisis, the 
contraction being more marked at the apex and the clavicles 
being very prominent. Chronic pleurisy, and still more fre- 
quently empyema, often give rise to unilateral contraction 
or even incurvature. There is a peculiar deformity called 
pectus carinatum or pigeon-breast, which consists in a great 
prominence of the sternum with trough-shaped depressions 
at the junction of the ribs with their cartilages. It is usually 
— in children always — the result of rachitis, but in adults 
may be due to osteomalacia. 

(6.) Sternum and Ribs. 

1. The sternum presents occasionally curvatures and in- 
dentations varying in degree, which may depend on a devia 
tion from the perpendicular in the skeleton as a whole, or be 
due to the occupation of the person (shoemakers, etc.). Con- 
genital defects in the bone also occur, and may assume the 
form of genuine fissures, or, what is more common, of small 



104 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

round holes in the median line, which are sometimes multiple. 
The ensiform cartilage is very often cleft and hence double. 

2. The ribs are not infrequently the seat of congenital 
fissure which may involve the cartilage alone, the bone alone, 
or both at the same time ; the second is perhaps the most 
frequent. Ecchondroses and exostoses occur both on the car- 
tilages and bones and may unite contiguous ribs. This is 
often the case after fractures. Fractures of the cartilages 
may heal by either bony or fibrous union. 

2. OPENING THE THORAX. 1 

We can now proceed to remove the anterior wall of the 
chest. The cartilages of the ribs are to be divided with. a 
stout knife a few millimeters from their insertions into the 
bony ribs, the knife being kept as nearly parallel with the 
surface as possible to avoid injuring the lungs or the heart. 
If pneumo-thorax be suspected it should be noticed whether 
there is any escape of gas at the first cut. 'A lighted match 
held over the opening will either flare up or be extinguished 
if gas is present, and its escape can thus be demonstrated to 
lookers on. 

If the cartilages have become calcified, it is better to divide 
the ribs themselves just outside of the insertion of the carti- 
lages with a saw or bone-nippers. The clavicles are then to 
be disarticulated from the manubrium of the sternum by 
semilunar incisions with the convexity directed inwards, and 
in the latter part of the incisions the handle of the knife is 
to be somewhat depressed backwards to avoid the lower and 
inner prominence of the articular surface of the clavicles. 
The cartilage of the first rib, which lies somewhat farther 
from the median line than those of the other ribs on account 
of the greater width of the upper piece of the sternum, is 
then to be divided with the knife, or, if ossified, with the for- 
ceps. If the knife be used its point should be inserted ver- 
tically into the first intercostal space close up to the cartilage 
and the handle then depressed. If this be done carefully 
injury to the subjacent great vessels may be avoided. 

1 See Plate. 



r JM 




y 



\ 




y, ^ 



- 



-v. 



Il 



\ ,00 



""HUPP* 





THE THORACIC CAVITY. 105 

The attachments of the diaphragm, which are included be- 
tween the two great lines of incision, are then to be severed 
close to the false ribs and the ensiform cartilage, and the 
sternum being drawn strongly upwards, the mediastinum is 
separated from the bone by transverse cuts, great care being 
taken not to injure the pericardium and great vessels. In 
case, however, the vessels should be cut, they must be imme- 
diately tied, or, at all events, closed with a sponge, to pre- 
vent the escape of blood into the pleural cavity. 

3. THE INNER SURFACE OF THE BONE. 

(a.) The chief affections of the inner surface of the ster- 
num are caries and erosion (fibrous atrophy). The former 
is usually of a tubercular character, and starts from cheesy 
mediastinal lymphatic glands, while the latter is often the 
result of pressure of an aneurismal tumor, and may go on 
to perforation. The marrow of the sternum can be exposed 
by a longitudinal incision ; it is of a red color even in adult 
life, and often presents leucaemic, tubercular, and other 
changes, identical with those found in the bones of the ex- 
tremities. 

(&.) The portions of the ribs which contain the centres 
of ossification, are decidedly enlarged and swollen in rickety 
children, and these swellings, taken all together, form what 
has been termed the rosary of rickets. On cutting into these 
enlargements they are seen to consist chiefly of a soft, gray 
tissue, into which the normal, milk-white, hyaline cartilage 
has been converted, and, instead of the narrow, white line 
which normally exists close to the bone, a broad, irregular, 
and indented stripe is to be seen. In longitudinal sections, 
prepared for the microscope, and examined in a solution of 
common salt, or, still better, in iodine, very marked hyper- 
plasia of the cartilage cells is seen, and both the cells and 
the intercellular substance are more transparent than in the 
normal condition. The zone of ossification between the en- 
largements and the bone (normally very narrow and with 
perfectly even edges) is converted into a broad, usually. 



106 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

though, not necessarily, calcified, layer, with irregular pro- 
jections into the cartilage. Great numbers of medullary 
spaces and vessels, both of which are here entirely out of 
place, are seen to have made their way from the medullary 
spaces of the bone far into the cartilage. 

Caries of the ribs as well as of the sternum, may also be 
found, and often takes its origin from inflammations of the 
pleura. 

This seems a suitable place for a brief description of the 
changes which take place in the costal cartilages as age 
advances. These changes can be studied to great advantage 
in fresh sections, and are typical of pathological processes of 
great importance. 

The cartilage early acquires a brownish shade which be- 
comes gradually deeper, and is due to a finely granular opac- 
ity of the intercellular substance ; the cells are enclosed in 
a thick capsule, which is often seen to consist of several lay- 
ers, and to show active proliferation. Here and there the 
naked eye can discern small spots with a lustre like that 
of asbestos, in which the intercellular substance has under- 
gone fibrous degeneration, while the cells have increased 
greatly in numbers, and form large, elongated masses. This 
fibrous degeneration of the intercellular substance is the 
forerunner of mucous degeneration of the same, and the 
last change is calcification, which also takes place in small 
spots appreciable to the naked eye; these differ from the 
spots of fibrous degeneration in being hard and of a chalky 
whiteness. The microscope reveals the presence of very 
minute collections of lime salts which are black by transmit- 
ted and white by reflected light, are readily soluble in hy- 
drochloric acid, and appear first at the extremities of the 
somewhat elongated capsules, and later completely fill the 
cells. 

(<?.) The stemo-clavicular articulation is often the seat of 
chronic rheumatic arthritis, and often of purulent (metas- 
tatic) inflammation, with caries of the articular ends. The 
clavicle should also be examined for fractures, whether re- 
cent or old, tumors, etc. 



THE MEDIASTINUM. 107 

4. INSPECTION OF THE THORACIC CAVITY. 

(a.) After the sternum has been removed, the degree of 
distention and general appearance of the lungs as far as ex- 
posed, should be noted. Healthy lungs collapse from their 
inherent elasticity when the thorax is opened. They may, 
however, be prevented from collapsing by loss of elasticity, 
by inflammatory adhesion to the chest wall, by the presence 
in the alveoli of solid or liquid substances, or by pent-up 
air — as in stenosis of the larynx or trachea. 

Complete distention of the lungs, as seen in those dead 
of drowning or suffocation, is very characteristic. The color 
of the lungs depends on the amount of pigment (carbon) 
they contain in the first place, and in the second on the 
amount of blood and the presence of certain pathological 
products. 

(b.) The condition of the pleural cavity, and the presence 
of any abnormal contents (the description given in connec- 
tion with the abdominal cavity applies also here) are then 
to be noted. If, as is so very often the case, the pleural 
surfaces be united by inflammatory adhesions of connective 
tissue, these should be torn if of moderate extent and tough- 
ness, for it often happens that they cover an exudation in 
the inferior and posterior portions of the cavity. If, how- 
ever, the adhesions are very extensive and tough, as they 
become with age, it is better to postpone further manipula- 
tion until, after having removed the heart, the lungs are 
removed in their turn. The mediastinum should also be 
examined, including the thymus gland, and the external 
appearance of that portion of the great vessels which lies 
without the pericardium ; the degree of fullness of the veins 
should also be noted, but the vessels must on no account be 
opened as yet. 

5. THE MEDIASTINUM AND ITS CONTENTS. 

(a.) Artificial emphysema of the connective tissue of the 
mediastinum is very apt to be caused by the removal of the 
sternum, and is chiefly marked over the heart, while patho- 



108 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

logical emphysema, from rupture of the pulmonary tissue, is 
generally found higher up, and very often extends into the 
neck. Hemorrhages, apart from those of traumatic origin, 
are found in this situation in phosphorus poisoning, acute 
yellow atrophy of the liver, etc., in great number. Suppura- 
tive inflammation sometimes extends from the neck hither. 
Clinical observers have of late had their attention directed 
to chronic inflammations of this part (mediastinitis chronica 
fibrosa), leading to fibrous thickening, induration, opacity 
and whiteness of the connective tissue. 

(5.) A cheesy (tubercular) condition of the lymphatic 
glands of the mediastinum is not infrequently met with in 
adults, but is still more common in children. 

(<?.) The thymus gland attains its full development at the 
end of the second year, and then begins gradually to dis- 
appear, though it may persist to the thirtieth year, or even 
longer. In still-born children it often contains numerous 
hemorrhages. Suppurative inflammation (syphilitic?) and 
cheesy degeneration are very rare. This gland is some- 
times the starting point of large nodulated tumors which 
resemble the lymphatic glands in structure, and may oc- 
cupy the whole mediastinum, or even extend above the 
sternum (lymphosarcoma thymicum). 

6. THE PEEICAEDIUM. 

To open the pericardium a longitudinal fold should be 
raised at the middle point of the anterior surface and a small 
incision should be made through its left side. Two fingers 
should then be introduced into the cut, and, just as in open- 
ing the abdominal cavity, it should be prolonged between 
them as far as the diaphragm, first downwards and to the left, 
and then downwards and to the right. The last step in open- 
ing the pericardium is to draw the right border of the first 
cut forwards and then to carefully prolong the incision up- 
wards as far as the point of reflection from the great vessels. 

If the sac contain much fluid it is better to scoop this out 
before making the last incision, which would allow its escape 



THE PERICARDIUM. 109 

and thus render accurate quantitative determination impossi- 
ble. As a rule, however, it is better to wait till the sac is 
completely opened before the fluid, which normally never ex- 
ceeds a teaspoonful, is removed. The fluid collects chiefly 
behind the heart, and to reach it the apex of the organ should 
be raised. 

(a.) Contents. 

What was said in connection with the contents of the peri- 
toneum holds good here also, but there are a few special 
points to which we shall refer. Though normal pericardial 
fluid never contains flakes of fibrine, it may coagulate on 
exposure to the air, so this fact alone should not induce one 
to diagnosticate inflammation. Hemorrhage in the peri- 
cardial as in the peritoneal sac may come either from the 
great vessels, from the heart, or from newly formed vessels 
of inflammatory origin. In the latter case the blood is 
mingled with the fluid of exudation, while in the former it is 
coagulated in large masses which may completely envelop 
the heart. Fluid blood is never the result of simple haemor- 
rhage, but depends on injury, spontaneous rupture of the 
heart, or some other condition which will be revealed during 
the subsequent examination. 

(bS) Morbid Conditions of the Pericardium. 

The most important of these are those due to — 

1. Inflammation. Simple fibrinous inflammation may be 
attended with the formation of a dry exudation small in 
quantity (dry pericarditis}, or of an abundant sero-fibrinous 
exudation (sero-fibrinous pericarditis}. The first may be 
hard to observe ; the second is always easily recognized. 
In the first form the membrane is generally much reddened, 
especially in the transverse furrow where minute haemor- 
rhages may be found, and its surface has lost its lustre and 
become opaque, as may be best seen by oblique light. 

When the effusion is slight, the fibrinous layers often have 
a very characteristic form in consequence of the cardiac 
movements. Warty and villous projections of varying height 
lie upon the surface, especially upon that of the posterior 



110 DIAGNOSIS IX PATHOLOGICAL ANATOMY. 

wall of the right ventricle ; ridges are also prominent, espe- 
cially in front over the origin of the pulmonary artery. This 
condition is so peculiar that it has given rise to the term cor 
villosum. 

Suppurative pericarditis is less common, and if it can- 
not be attributed to injury, suppurative mediastinitis, caries 
of the ribs, or gangrene of the lung, when the pus is often 
fetid, is very apt to be of metastatic origin. In many cases 
we may be able to discover on either the parietal or visceral 
(epicardium) layer the point from which the process started, 
in the form of a circumscribed patch of more intense inflam- 
mation, or perhaps of an actual necrosis. 

The pericardium, normally, is a thin and perfectly trans- 
parent membrane, but is often the seat of a more or less cir- 
cumscribed thickening and milky opacity, the result of cir- 
cumscribed chronic inflammation : such spots are not of great 
importance. Sometimes, precisely at these spots, the re- 
mains of old and more intense inflammation are found in the 
form of fibrous adhesions between the two layers of the mem- 
brane, but these are not nearly so common as in the pleural 
cavity ; or the layers may be closely united over a consider- 
able, or even the whole, area {obliteration of the cavity), at 
times to such a degree that they cannot be separated. If a 
fibrinous or purulent exudation preceded the formation of ad- 
hesions, it may have become wholly absorbed, or portions 
may have become cheesy and calcified, and thus persist as 
cheesy and cretaceous nodules, or bone-like masses in the 
midst of the fibrous adhesions. 

2. Tubercles are very often found in connection with these 
remains of former inflammation, and are apt to be imbedded 
in the adhesions (pericarditis fibrosa tuberculosa). In gen- 
eral tuberculosis the tubercles may exist without giving rise 
to inflammation (tuberculosis pericardii), in which case the 
tubercles are usually scattered along the course of the vessels, 
but they may also be associated with fibrinous, hemorrhagic 
inflammation. In the latter case they may be completely 
hidden by masses of fibrine, which should therefore always be 



THE HEART. Ill 

detached at several points and the condition of the subjacent 
membrane examined. The occurrence of tubercular pericar- 
ditis in old people without the existence of any discoverable 
cheesy focus deserves special mention. Cheesy nodules of 
tubercular character rarely attain great size in this situation. 

3. Secondary nodules of carcinoma, sarcoma, etc., are quite 
rare in this locality. 

(<?.) Changes in the Subpericardial Fatty Tissue. 

The subpericardial fatty tissue varies widely in quantity 
and is not always proportional to the panniculus adiposus. 
In cachectic states it is found to have undergone a pecul- 
iar change, being transformed into a soft transparent and 
gelatinous mass, which shows a whitish opacity on the addi- 
tion of acetic acid, and under the microscope is seen to 
consist of a transparent finely fibrillated substance which re- 
acts like mucine and in which are imbedded large cells con- 
taining either fat drops or serous fluid Qniucous metamor- 
phoses). Small lipomata are sometimes found, especially 
toward the apex. Special medico-legal interest attaches to 
the presence of small haemorrhages into this tissue, the so- 
called subpericardial eechymoses. They are most common at 
the base and on the posterior wall, and are very liable to 
occur in death from suffocation. 

7. THE HEART. 

(#.) External Examination. 

Before any incision is made into the heart or it is removed 
from the body, its position, size and form, color and consis- 
tency (whether contracted or not) are to be noted, as well 
as the degree of fullness of the coronary vessels and of the 
individual compartments (auricles and ventricles) of the 
heart. 

1. The heart may be pushed out of position by pleuritic 
effusion, etc., or it may be hypertrophied and its boundaries 
thus changed. The position of the apex is an important in- 
dication and is not infrequently found to be in the axillary 
line. 



112 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

2. The closed fist of the right hand is a very good standard 
of comparison for the size of the normal heart. Bizot has 
found the average dimensions between the ages of twenty and 
sixty years to be as follows : length, 85-90 millimeters in the 
male, 80-85 mm. in the female ; breadth, 92-105 mm. in the 
male, 85-92 mm. in the female ; thickness, 35-36 mm. in the 
male, 30-35 mm. in the female. The size is diminished, 
sometimes excessively, in all cachectic diseases, and often in 
chronic pericarditis with abundant effusion ; it is increased 
in diseases of the heart itself as well as in those of other 
organs, such as the lungs, kidneys, aorta, etc. ; when due to 
diseases of other organs the enlargement is usually partial. 

3. Alteration in form depends generally on enlargement 
predominating on one side or the other. In enlargement of 
the left ventricle the organ is elongated and relatively nar- 
row, conical or cylindrical ; while in enlargement of the right 
ventricle the chief increase is in the transverse diameter. 
The formation of the apex affords a good indication of the 
presence or absence of enlargement of the right side. In the 
normal heart the apex is formed solely by the left ventricle, 
but when the right ventricle shares in its formation an en- 
largement has taken place. A depression of greater or less 
depth is sometimes met with between the apices of the ven- 
tricles as a congenital deviation from the normal form. 

4. The color of the heart's surface depends largely on the 
condition of the pericardium and its subjacent fat. The 
auricles are dark blue in color, especially when distended 
with blood ; but the color of the ventricles depends in great 
measure on the condition of the muscular substance, which 
will be considered later. 

5. The consistency of the different portions depends chiefly 
on the degree of muscular contraction, but in a measure also 
on the amount and character of their contents. In simple 
contraction nothing like a cavity can be felt through the 
muscular wall, while in simple distention the contents always 
yield somewhat to pressure. 

6. The coronary arteries and veins are readily distinguished 



;-5--* • 3?>w 



/ 

■ - 



sSSS^Ssfo.* 



THE HEART. 113 

from each other by the difference in the thickness of their 
walls and in their course. Marked distention, particularly 
of the larger veins, points to an impeded flow of blood from 
the right auricle (suffocation, etc.), provided that such dis- 
tention be not confined to the posterior surface of the organ 
(hypostasis), while an almost empty condition may depend 
on general ansemia or on calcification or endarteritis of the 
coronary arteries. These latter changes may often be recog- 
nized externally by the rigidity, hardness, and whitish-yellow 
color to which they give rise. 

7. The degree of distention of individual portions of the 
heart is often indicated by the external shape. If the surface 
be flat or sunken, the contents must be small in amount, but 
if it be convex and tense, the contents must be considerable. 
The right heart is abnormally distended in death from suffo- 
cation in its various forms ; the left heart in death from 
cardiac paralysis. 

In order to determine the quantity and character of the 
blood contained in the individual cavities, they must be 
opened while the.heart still remains connected with its nat- 
ural attachments. 

(5.) Opening the Heart in situ. 1 
To open the right side the left hand should be so placed 
under the posterior surface of the organ that the forefinger 
lies in the transverse furrow, and the thumb a little behind 
the sharp right border of the right ventricle. By now draw- 
ing the heart somewhat downwards and to the left, and mak- 
ing it tense over the left forefinger, the points at which the 
venae cava? empty into the auricle are brought into view. 
The incision into the auricle should begin between the cava?, 
be prolonged as far as the transverse furrow, there intermit- 
ted for the space of about one centimeter, in order to avoid 
the tricuspid valve, and then again continued in the same di- 
rection as far as the right border of the right ventricle, but 
not prolonged as far as the apex on this side, the apex being 

i See Plate. 
8 



114 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

normally composed entirely of the left ventricle. After re- 
moving and examining the contents of the auricle and then 
of the ventricle, two fingers of the left hand should be intro- 
duced from the auricle into the tricuspid valve, which should 
be large enough to allow the introduction of still a third 
finger between the other two. The left ventricle should 
then be grasped in the left hand in such a way that the apex 
lies in the fold between the thumb and forefinger, the first 
on the posterior, the second on the anterior surface of the 
heart ; or else the organ may be taken in the palm of the 
hand with the thumb on the anterior and the fingers on the 
posterior surface, drawn downwards and to the right, and an 
incision made into the auricle in the upper of the two left 
pulmonary veins, which are thus clearly brought into view. 
At the transverse furrow the cut should be interrupted and 
then continued again at the left border as on the right side, 
except that here it is to be prolonged as far as the apex. 
The contents of the cavities should then be examined, and, 
after having overcome the rigor mortis, the size of the mitral 
valve is determined. This should admit two fingers with ease. 

(<?.) The Blood. 

The changes undergone by the blood are some of them 
gross, some microscopic ; some depend on quantitative or 
qualitative modifications in the constituents of the blood, 
others on pathological admixtures with other substances. 
The latter, as a rule, cannot be recognized without the aid 
of the microscope. 

1. Coagulation is subject to the greatest variations, since 
the blood may be found in any condition between the ex- 
tremes of entire fluidity, and coagulation into very dense and 
firm masses of fibrine, containing scarcely any red corpuscles 
(polypi of the heart). The presence of firm eoagula of pure 
fibrine, particularly when they are attached to the wall of the 
heart, indicates that death came on so gradually (the action 
of the heart growing weaker and weaker) that the fibrinous 
portion of the blood was deposited by degrees on the walls, 



THE HEART. 115 

while the corpuscles were still kept in circulation. Fibrinous 
coagula may, however, also occur in consequence of the pres- 
ence of an increased amount of fibrine in the blood ; as, for 
instance, in acute inflammatory affections. In this case the 
fibrinous masses are not so strictly limited to the walls, but 
all the clots contain large quantities of this substance. The 
amount of fibrine, moreover, varies somewhat with the situa- 
tion of the clot, even when the blood, as well as the coagula- 
tion itself, is perfectly normal. The clot which occupies 
the conus arteriosus of the right ventricle and the commence- 
ment of the pulmonary artery is almost always very rich in 
fibrine. Firm and voluminous coagula are often marked 
with moulds of the inequalities of the wall — the sinuses of 
Valsalva, the musculi pectinati, etc. 

Coagulation may be incomplete or entirely wanting, in con- 
sequence either of diminution in the amount of fibrine (hy- 
pinosis), as in dropsical blood, or of the presence of certain 
substances which prevent coagulation, the first place among 
which belongs to carbonic acid. All processes, therefore, 
which overload the blood with carbonic acid diminish or pre- 
vent coagulation ; such are all affections which end in suffo- 
cation, as well as those where death is directly dependent on 
closure of the air passages from without. 

2. Another peculiarity of the blood in these cases is its 
dark color, though the distinction between arterial and ve- 
nous blood gradually disappears after death, and the blood of 
the pulmonary veins even becomes dark (venous). In cases 
of poisoning with carbonic oxide gas, the ha^moglobine unites 
with the gas and imparts a bright cherry-red color to the 
blood. 

Decomposition brings about marked changes in the color 
of the blood. The coloring matter leaves the solid constitu- 
ents and is taken up by the serum, the color becomes indis- 
tinct and dirty, and on standing, the superficial layer of clear 
serum which is formed in healthy blood does not appear. 
The microscope shows that the red blood disks have lost 
their color, and have become converted into pale globular 
bodies, which float in a yellowish -green fluid. 



116 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

3. Changes in the composition of the blood also produce a 
varying appearance. These are due to deviations from the 
normal proportion between the blood corpuscles and the 
serum on the one hand, and the red and white corpuscles on 
the other. If the serum is diminished, the blood becomes 
thick, even resembling tar, as in cholera; if increased, the 
blood becomes watery or hydremic, as in some affections of 
the heart, lungs, kidneys, and liver. A similar effect may be 
produced by a diminution of the cellular elements, either of 
both together or of the red alone, but in this case the blood 
mass is diminished, while in hydraemia it is increased. In 
either case the blood is pale in color. In no affection are the 
cellular elements so much diminished as in pernicious anse- 
mia, so called, in which disease the blood in many situations 
may resemble a faintly colored serum. 

Increase in the white corpuscles causes still other modifica- 
tions in the appearance of the blood ; this takes place in a 
moderate degree in the acute inflammatory, infectious, and 
other diseases, but is most marked in leucaemia. There is, 
however, more than a mere difference in degree under such 
circumstances : in the former class of affections the white 
corpuscles are increased merely (leucocytosis), but in leucae- 
mia the red cells are also diminished. 

The appearance of the white corpuscles themselves is some- 
what modified in leucaemia, and indeed in such a way as to 
indicate their origin. The ordinary white corpuscles consist 
of a granular protoplasm, the single or multiple nuclei of 
which come out distinctly only after the addition of water 
or, better still, of acetic acid. Leucaemic cells, however, are 
either larger with a single distinct nucleus, — splenic cells, 
splenic leucaemia, — or else smaller with a very large nucleo- 
lated nucleus, and but little protoplasm, — lymph-gland cells, 
lymphatic leucaemia. In some cases nucleated red corpus- 
cles are found, that transitional form between the red and 
the white corpuscles occurring normally in the embryo, 
and which, as has been shown by Cohnheim, is also found in 
the blood and bone marrow in cases of pernicious anaemia. 



THE HEART. 117 

In moderate cases of leucaemia the blood is of a light rasp- 
berry-red color, but in very severe cases, and particularly at 
the junction of the thoracic duct with the right auricle, it has 
a yellowish color, and looks not unlike pus. The red corpus- 
cles are then often collected in the form of small red stripes 
between the pale coagula. The white corpuscles often pre- 
sent a peculiar arrangement in simple leucocytosis, collecting 
in small groups which vary in size between that of a poppy- 
seed and that of a grain of millet, but rarely exceed the lat- 
ter, and may bear a close resemblance to tubercles ; these 
groups are best seen in the coagula from the pulmonary ar- 
tery, and are found in the very finest branches of that vessel. 

4. We now come to the last class of modifications in the 
blood, those, namely, which are due to its admixture with 
abnormal morphological material. 

(«.) Cellular elements sometimes find their way into the 
blood. The blood of the splenic vein, and occasionally also 
that of the peripheral vessels, in typhoid and typhus fever, in 
particular, often contains white corpuscles in which one or 
several red blood-disks are imbedded ; such cells may 'also be 
found in the spleen, lymphatic glands and bone marrow. 
Fatty degenerated endothelial cells from the walls of the 
blood-vessels also occur. In those cases in which it can be 
demonstrated that portions of a morbid growth have been 
carried into other organs by the blood-current, — as is some- 
times the case with the melano-sarcomata, etc., — as well as 
in those cases in which a soft morbid growth makes its way 
into the larger veins (sarcoma of the kidney, for instance), 
cells derived from the growth may possibly be found in the 
blood. 

(ft.) Two distinct kinds of abnormal coloring matter are 
sometimes found in the blood. In the first place, irregularly 
shaped granules, which may be reddish or brownish, but are 
generally almost black, and are evidently derived from the 
blood-pigment ; these are sometimes found in all parts of 
the body, though chiefly in the blood of the splenic vein, both 
free in the serum and imbedded in the colorless colls, con- 



118 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

stituting melancemia. In the second place, the coloring mat- 
ter of the bile may find its way into the blood, and occur 
either in solution or in the form of crystals. In solution 
it is found chiefly in the jaundice of adults, and betrays its 
presence by imparting the yellow color of bile to the fibri- 
nous coagula. In the form of pointed, acicular, brownish-red 
crystals of bilirubine it occurs as a post-mortem change in 
the blood in icterus neonatorum, and in the acute yellow 
atrophy of the liver of adults. In the former case the crys- 
tals are often so numerous that their presence may be recog- 
nized by the naked eye by the reddish-yellow color which the 
fibrinous coagula retain even after being thoroughly washed 
in water. 

(c.) A milky, opaque condition of the blood is due to the 
suspension in it of very minute fat drops, and is known as 
ehylcemia. 

(<#.) Of all the modifications which the blood undergoes, 
the least understood, and, at the same time, the most impor- 
tant, is unquestionably that which is due to an admixture 
with low organisms. Recent researches leave no doubt what- 
ever that in some diseases the blood contains during life, 
though to a far higher degree after death, certain low forms 
of animal or vegetable life. Those organisms which have a 
thoroughly characteristic appearance can be detected without 
any great difficulty with very high powers, provided that 
the layer of blood which is examined be very thin or that the 
red corpuscles have been destroyed with acetic acid or alka- 
lies. The number of diseases in which these organisms are 
found is small. During the paroxysms of relapsing fever the 
blood contains delicate, spiral, thread-like bodies (spirilla) 
which move by turning in the direction of their axes and 
disappear after death. In anthrax or malignant pustule, a 
rare affection in the human subject, the blood contains small 
rod-like bacteridia which are often joined together as long 
serpentine threads. These are, indeed, not constant, but may 
be replaced by exceedingly minute spherical bodies (micro- 
cocci), the detection of which requires very high powers. 



THE HEART. 119 

They can be easily distinguished from the rod-like bacteria 
seen transversely, by gently tapping on the cover glass and 
thus causing movement in the fluid. They lead us to the 
consideration of a second group of parasites, the certain diag- 
nosis of which is difficult and sometimes, indeed, impossible. 
It has long been known that extremely minute, spherical 
granules are found in the blood in health, but in far greater 
numbers in any or every kind of disease, the formerly so- 
called primitive vesicles. They are to be regarded as in part 
portions of the red blood corpuscles, in part of the white cor- 
puscles, and again in part as fat molecules resulting from the 
fatty degeneration of cells. They cannot be distinguished 
from parasites with certainty, even with the aid of reagents, 
inasmuch as both show molecular movement. If, however, 
the micrococci, instead of being isolated, are united in rosary- 
like chains, their nature is less doubtful. It is true that fat 
granules may give rise to a similar appearance, but this is 
very unusual, and fat granules are seldom so uniform in size 
as micrococci. If, therefore, chains of equally sized spherules 
are found in the blood, they can be diagnosticated as micro- 
cocci with a certainty which is somewhat proportional to 
their numbers. The most characteristic form in which mi- 
crococci occur, is that of large collections or groups in which 
the separate granules preserve a uniform size and a uniform 
distance from each other. 

Hitherto we have confined ourselves solely to the presence 
of parasites in the serum of the blood, but many authorities 
refer to their being contained in the cellular elements. The 
white corpuscles are so prone to take up all manner of 
strange substances (granules of coloring matter, etc.) that it 
is not surprising if they take up these bodies also, but it ap- 
pears to me very questionable whether the red corpuscles do 
so. Those irregularities in the outline of the red corpuscles 
which are due to evaporation and shrinkage may easily be 
misinterpreted in cases of septicemia and the like, especially 
if the edge of the corpuscle lies uppermost and presents these 
irregularities to the observer, in which case they look like 



120 DIAGNOSIS IN PATEOIOGICAL ANATOMY. 

superimposed minute granules. To avoid this source of error 
one should always add water to the specimen and thus cause 
the corpuscles to swell. Micrococci have been found in 
the blood in the most various diseases, but chiefly in septicae- 
mia, puerperal diseases, diphtheritis, etc. They are, however, 
not constant even in these affections. The best method of 
rapidly determining the presence or absence of parasites in 
the blood is to treat it with acetic acid or a dilute alkali, 
both of which reagents dissolve the red corpuscles as well as 
any fibrinous coagula which may have formed. 

Decomposed blood always contains all sorts of micrococci, 
bacteria, etc., and the latter are often in active movement, 
especially if a slight degree of heat be applied. 

(e.) Decomposed blood often contains bubbles of gas also, 
sometimes in such numbers as to give rise to a frothy appear- 
ance. Air-bubbles in fresh blood, especially when found in 
coagula, suggest that air made its way into the veins during 
life. 

(<:2.) Removal and Complete Opening of the Heart. 

The heart is removed from the body by inserting the left 
thumb into the right and the forefinger into the left ven- 
tricle, and then drawing the organ well upwards, the vena 
cava, pulmonary veins, and both large arteries are severed 
from below as far from the heart as possible. The possibil- 
ity of closure of the semilunar valves should then be tested 
with water. In doing this, care should be taken that all coag- 
ula have been removed from the orifice, and that no tension 
be exerted on the valves ; the heart should, therefore, neither 
be laid on the hand nor be hung from the attached vessels, 
but should be held by the auricles in such a way " that the 
plane of the orifice which is being examined is perfectly hor- 
izontal and not distorted in the least." (Virchow.) Care 
must also be taken to avoid injury to the coronary arteries, 
through which the water might escape and thus another 
source of error arise. 

After having laid the heart on a dish in the position 
which it occupies in the body, in order to leave the tricuspid 



THE HEART. 121 

valve untouched, a cut is to be made from above the papil- 
lary muscle, which occupies the anterior wall of the right ven- 
tricle, into the pulmonary artery ; this cut should be made as 
far to the left as possible, for the reason that two segments 
of the valve come together at this point and both may thus be 
left intact. The cut which lays open the left ventricle is to 
be begun at the apex, carried along near the septum, and 
then between the auricle and the pulmonary artery into the 
aorta. One of the segments of the semilunar valve lies 
directly in the path of the cut, and hence must unavoidably 
be divided. 

(e.) The Interior of the Heart. 

1. General Appearances. 

We are now able to determine the size of the ventricles 
and their relation to that of the heart, as well as the condi- 
tion of the muscular substance, its thickness, color, consist- 
ency, and special affections. The walls of the right ventricle 
between the trabecule are nominally 2-3 millimeters thick 
(the figures are usually rather smaller in the female than in 
the male), but pathologically may be 7-10 millimeters, or 
even more in thickness. The left ventricle is nominally 7-10 
millimeters thick, but may reach 15-25, or more. The papil- 
lary muscles and trabecular often, but not invariably, partici- 
pate in modifications in the thickness of the wall ; in case, 
for instance, of great intraventricular pressure, the papillary 
muscles are very thin and flattened although the walls are 
enormously hypertrophied. In estimating the increase or 
diminution of the myocardium it should be borne in mind 
that the thickness of the wall affords an indication only of 
relative, not of absolute, atrophy or hypertrophy. To deter- 
mine the latter the size of the cavities must also be taken 
into consideration. In marked dilatation there may be an 
absolute increase in the muscular tissue, although the thick- 
ness of the wall is below the average, and when the wall is 
thickened, the absolute muscular hypertrophy is greater in 
proportion to the dilatation. In very anaemic persons in par- 



122 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

ticular, hypertrophy may be simulated by a simple contracted 
condition of the muscle ; this, however, can be easily over- 
come and then the real thickness of the wall appears. 

The weight of the organ affords the most accurate indica- 
tion of absolute hypertrophy. The average weight in women 
is 250 grams, in men 300 grams, but pathologically may 
reach 500-1,000 grams. 

The color of the myocardium depends greatly on the 
amount of blood present, but is always of a more grayish- 
red than the voluntary muscles, and is paler. It may be 
more or less brownish-red or, even in conjunction with anse- 
mia, simply brown ; or it may be more or less yellow, at 
times almost of the color of butter. This yellow color is not 
uniformly diffused as a rule, but is apt to be confined to 
either the outer or inner layers and appears in the form of 
small specks or intersecting lines, especially in the papillary 
muscles. 

The consistency occupies a certain relation to the color, 
brown hearts being quite firm, while yellow hearts are soft 
and flabby in proportion to the depth and extent of their 
yellowness. The consistency also increases as a rule with 
the degree of hypertrophy, and may become almost like that 
of a board ; this hardness is also associated with rigidity, and 
a collapse of the walls of the ventricles, particularly of the 
right, is thus prevented after the heart has been opened. 
Decomposition renders the muscular substance flabby and 
imparts to it a dirty red color. 

2. Special Morbid Conditions. 

(a.) Of the Muscular Tissue. 

Atrophy and hypertrophy are the most common patholog- 
ical conditions. 

(#.) The commonest form of atrophy, again, is that to 
which the term brown atrophy has been applied, and which, 
as the name indicates, is characterized by a more or less dis- 
tinct brownish color and a general atrophy of the muscular 
structure. 



THE HEART. 123 

Needle preparations show that this discoloration depends 
on the presence of irregular brownish granules, which are 
first deposited at the ends of the nuclei (in the mascular 
corpuscles), and later elsewhere between the fibrils. The 
broad, dark, transverse strise which normally limit the ter- 
ritories of the individual cells become very strongly marked 
in this affection. Brown atrophy appears physiologically with 
advancing years, and is also associated with all cachexias, 
whether of phthisical, cancerous, or other nature. 

A second form of atrophy is caused by penetration of the 
external fatty tissue between the muscular layers, on which it 
exerts a mechanical pressure. In such hearts one is imme- 
diately struck with the large quantity of subpericardial fat, 
which sends out projections of varying width into the muscle, 
— in the right heart even as far as the endocardium, — thus 
producing a fatty infiltration. This is the so-called obesity of 
the heart. Microscopic specimens show distinctly that fatty 
tissue is really present between the muscular bundles, and 
it is evident that the general color of the heart must become 
essentially modified in consequence. 

This fatty infiltration of the cardiac walls must not be 
confounded with the third form of atrophy, — fatty degenera- 
tim, — which differs from the two other forms in being still 
more limited to individual fibres, and often occurring in hearts 
which are absolutely enlarged. 

Scattered about here and there on the walls of one or 
both ventricles, and particularly on the papillary muscles, 
which are chiefly liable to suffer from mechanical pressure, 
etc., light yellow points may be observed, and also streaks 
which sometimes form a beautiful network or spotted ap- 
pearance. These places, when examined microscopically 
with a low power and transmitted light, appear as black 
spots ; but with a high power they are seen to consist of 
large and small highly glistening and dark-contoured glob- 
ules, the fatty nature of which is demonstrated by their 
remaining unchanged when treated with acetic acid and the 
dilute caustic alkalies. The fat drops are found between 



124 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the fibrils also, and the transverse striation becomes indis- 
tinct in the lower, while it is completely lost in the higher 
grades of fatty degeneration. 

Besides these partial forms, there is also a general fatty 
degeneration, in which the muscular tissue is of a uniform 
yellowish color, though rarely of so intense a shade as in the 
partial form ; both forms are not infrequently associated. In 
the lower grades of the affection under consideration, but es- 
pecially in partial fatty degeneration with dilatation, in con- 
sequence of valvular lesions, etc., the appearances are con- 
fined to — or at all events most marked in — the inner lay- 
ers of the wall ; fatty degeneration in the outer layers is 
always secondary, often associated with pericarditis, and be- 
trays its presence on the external surface of the organ. The 
higher grades of the process are found in acute yellow 
atrophy of the liver, phosphorus and arsenic poisoning, per- 
nicious anaemia, etc., and involve the entire thickness of the 
myocardium more or less uniformly. 

There is a peculiar form of fatty degeneration which ap- 
pears in circumscribed spots of varying size, usually in the 
left ventricle, and results from changes in the vessels. We 
do not allude to the local changes which are brought about 
by septic emboli, to be described in another place, but refer 
only to those pultaceous, fatty masses which are generally 
of some size, and lie near the apex of the left ventricle; their 
cause being sclerosis and calcification of the arteries, throm- 
bosis of the veins, etc. They give rise not infrequently to 
rupture of the cardiac wall and sudden death. 

It is sometimes important to be able to distinguish such 
ruptures — which are called " spontaneous " — from those 
of traumatic origin. Of course this can be done only when 
the injury was not the direct cause of a rupture through 
such a preexistent spot of softening. In traumatic cases the 
rent is generally larger, its edges are smooth and tolerably 
straight, and its neighborhood is neither infiltrated with 
blood nor shown by the microscope to be fatty degenerated. 
In spontaneous rupture, on the other hand, the rent is often 



THE HEART. 125 

very small, and its canal so irregular that a sound can be 
passed through it with difficulty ; the adjoining tissue is infil- 
trated with blood and the muscular tissue fatty degenerated. 

(5.) Hypertrophy may be confined to either side of the 
heart alone, or may affect both sides, and it is usually not diffi- 
cult to discover its mechanical cause. For instance, in insuf- 
ficiency and stenosis of the aortic valves, both ventricles are 
generally hypertrophied ; the left directly in consequence 
of the valvular lesion, the right secondarily from stasis of 
the blood in the pulmonary circuit, and the increased de- 
mand which is thus made upon it. Hypertrophy of the 
right ventricle may depend either on changes in the heart 
itself (stenosis and insufficiency of the mitral valve) or on 
changes in the lungs. If extensive destruction of the pul- 
monary capillaries has taken place, — from phthisis, for in- 
stance, — or if in any other way the circulation has been 
appreciably impeded, the explanation of the hypertrophy is 
easy ; we are, however, not yet able to give a satisfactory 
explanation for the fact that a higher degree of hypertro- 
phy is often associated with chronic bronchial catarrh than 
can be accounted for by the amount of emphysema present, 
or by other changes in the pulmonary parenchyma. Fatty 
degeneration confined to the right ventricle is very common 
in all these cases. The conditions which may give rise to 
hypertrophy of the left ventricle are much more numerous, 
and cannot be treated in detail here. We must, however, 
mention the interesting connection which exists between hy- 
pertrophy of the left ventricle and atrophy of the kidneys. 
Many recent writers have endeavored to connect hypertro- 
phy of the left ventricle and of the whole heart, without dis- 
coverable anatomical cause, with overwork — idiopathic car- 
diac hypertrophy. This condition is often met with in sol- 
diers, etc. 

(c.) Inflammatory changes may be divided into paren- 
chymatous and interstitial, the former involving the true 
muscular, the latter the intermuscular fibrous tissue, though 
it never occurs independently of the former. 



126 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

1. Parenchymatous changes may be either general or par- 
tial. The general form is found in almost all infectious dis- 
eases, and is characterized in its earlier stages by a grayish- 
red opacity of the flaccid muscular walls, while later fatty 
changes arise. The muscular fibres in the first stage, when 
examined microscopically, contain granules resembling those 
of fat but really of an albuminous nature, as is shown by 
their disappearance on the addition of acetic acid or the 
dilute alkalies. The partial form is a result of a plugging 
of the branches of the coronary arteries by septic emboli, as 
in puerperal fever, pyaemia, ulcerative endocarditis, glanders, 
etc. ; it is manifested by the presence of small abscesses as 
large as or somewhat larger than the head of a pin, which 
are generally multiple, with a red areola, and contain pus 
cells and a large amount of fatty degenerated muscular tissue 
(the second stage of parenchymatous inflammation). This 
affection is the precursor, as it were, of — 

2. Interstitial inflammation, since the pus cells are to be 
regarded as evidences of acute, purulent, interstitial inflam- 
mation (interstitial suppurative myocarditis). The malig- 
nant character of the emboli is explained by the usual pres- 
ence of collections of micrococci within them, such as are 
also to be found at the point from which the embolus was 
detached. 

Chronic interstitial inflammation is more common than 
the acute form, and may also be limited to small areas. It 
is attended with the formation of fibrous tissue, — chronic 
fibrous interstitial myocarditis, — which has replaced the 
muscular fibres at the surface of the apices of the papillary 
muscles, or at the surface of the trabecular, or else appears 
in the midst of the muscular wall in the form of dense 
gray streaks. In the latter case the changes are best 
brought to view by a horizontal cut through the muscular 
substance, for instance, through the triangular portion of the 
wall which results from the opening made into the aorta. The 
microscope reveals a conversion of the interstitial into cica- 
tricial tissue and an atrophy of the intermediate muscular 



THE HEART. 127 

fibres. There is a remarkable condition known as chronic 
saccular aneurism of the heart, the chief seat of which is the 
apex of the left ventricle. It depends on fibrous myo- and 
endocarditis, which may so diminish the thickness of the 
cardiac wall that the latter gradually yields to the pressure 
of the blood at this point, and may finally be ruptured. 

(df.) Among tumors we will first mention gummata, which 
sometimes are found in the form of large yellow nodules. 
Syphilis may also give rise to fibrous myocarditis, but, as in 
other organs, the true nature of this change can be recog- 
nized with certainty only when gummy formations are pres- 
ent at the same time. 

Tubercles occur occasionally in this situation in general 
miliary tuberculosis, but very rarely in the form of cheesy 
masses ; these are always here the result of syphilis. Sar- 
coma, and particularly myxosarcoma, may be primary in the 
heart ; so also myoma, with stellate, transversely striated 
muscle cells, in new-born children. Secondary nodules of 
general carcinoma, sarcoma, melanoma, etc., may also occur, 
and the latter may give rise to embolism of the pulmonary 
arteries. 

(e.) The entozoa are rarely formed in the heart. Tri- 
chinae are never found, but both cysticerci and echinococci 
have been known to occur. 

(/.) Among congenital malformations we will mention 
persistent patency of the foramen ovale, and deficiencies of 
varying size in the ventricular septum. The former is rela- 
tively common, but can be easily overlooked, as the com- 
munication between the auricles is not always direct, but 
may be formed by an oblique canal or fissure resulting from 
defective union between the membranes which are formed on 
either side and normally close the opening. Supernumerary 
muscular and tendinous bands are often met with, espe- 
cially between the anterior wall of the left ventricle and the 
septum. 

(/?.) Of the Endocardium. 

The last important part of the heart, the endocardium, is 



128 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

ordinarily nowhere separated from the myocardium by fatty 
tissue, but in very fat persons, as well as in those laboring 
under obesity of the heart, a thin layer of fat is sometimes 
deposited in this place. Such a layer is very sharply defined 
in a transverse section, and its glistening fat cells are suffi- 
ciently characteristic. Slight effusions of florid blood are 
also occasionally found in this situation. 

The endocardium is very often stained red by the color- 
ing matter of the blood, and this redness, apart from its 
diffuse and indistinct character, cannot be attributed to in- 
flammation on account of the low degree of vascularity of 
the membrane. 

Pathological conditions are found with far greater fre- 
quency in the valvular than in the parietal endocardium. 

(a.) The parietal endocardium is often the seat of cir- 
cumscribed fibrous thickening (chronic fibrous parietal endo- 
carditis*), especially in connection with superficial fibrous 
myocarditis. The membrane may also be the seat of general 
thickening with circumscribed verrucous and ulcerative inflam- 
mation (verrucous and ulcerative parietal endocarditis), the 
latter almost always an extension of similar changes in the 
valves ; the left ventricle is chiefly affected by this condition. 
Local ulceration of the parietal endocardium, by permitting 
the direct action of the blood current upon the muscular wall 
and the pericardium, may give rise to an aneurismal dilata- 
tion of a portion of the wall — acute aneurism of the heart. 

(b.) It is a well-known fact that valvular disease which 
has arisen during life is generally seated in the left heart, 
very rarely in the pulmonary, and only exceptionally in 
the tricuspid valve ; while during foetal life the valves of 
the right heart are much more liable to suffer than those of 
the left. The commonest pathological condition, generally 
associated with atheroma of the aorta, is not an inflamma- 
tory but a simple regressive metamorphosis, and appears as 
irregularly shaped yellow spots of varying size, which are 
due to fatty degeneration of the connective tissue corpuscles 
of the part, and do not interfere in any way with the func- 
tion of the valve. 



THE HEART. 129 

The most important pathological conditions are those 
which are due to inflammation (valvular endocarditis), and 
may be divided into two classes, acute and chronic. The 
line of closure of the valves is the favorite seat of both these 
classes of changes ; this lies at a little distance from the free 
borders of the curtains of the mitral, and in the segments 
of the aortic valves describes two curved lines which inter- 
sect the free borders at their middle points, the corpora 
arantii. Occasionally the changes are limited to the line 
of junction of the valves with the parietes (basilar valvular 
endocarditis), but they more commonly occur in both these 
lines at the same time. They first make their appearance, 
moreover, on that side of the valve which is turned toward 
the blood current — the ventricular surface of the aortic 
valves, the auricular surface of the mitral. 

We will take up the chronic form first on account of its 
greater frequency. This may be a simple fibrous thicken- 
ing of the valve curtains (chronic fibrous endocarditis), with 
which more or less retraction is apt to be associated ; if the 
mitral valve be thus affected, the process almost always in- 
volves some or all of the chordae tendineaB which are thick- 
ened and retracted. Fusion may also take place between 
the contiguous free borders of the segments, beginning at 
their extremities ; this condition occurs chiefly in the aortic 
valve, and gives rise to stenosis and insufficiency. Small 
papillary elevations sometimes occur in the valves, either in 
conjunction with or independently of these fibrous changes, 
and may become largely calcified, even of a stony hardness. 

The acute form may be either primary or the recurrence 
of a preexistent endocarditis. It, too, may be attended by 
the formation of soft papillary elevations on the line of closure 
of the valves, resembling a cock's comb, of a white or gray 
color and somewhat translucent ; these are shown by the 
microscope to consist of papillary connective tissue, which 
may perhaps be derived from the small projections which 
often are normally present in this situation. Or else we may 
find on the valves bodies varying in size between that of a 



130 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

cherry-stone and that of a hazel-nut, soft, gray, grayish-red, 
or grayish-yellow in color, and, as a rule, easily separable 
from their attachments ; the microscope and acetic acid show 
these to consist of fibrine derived from the blood. The sub- 
jacent surface of the valve is not smooth as in the pap- 
illary variety, but it is ulcerated and often increased in 
thickness (ulcerative endocarditis*). In the papillary variety 
the remaining portions of the curtains may be quite intact, 
while in the ulcerative form they are apt to be swollen 
and of a dirty yellowish hue. This form occurs chiefly 
in puerperal fever, pyaemia, etc., and has been called ma- 
lignant or diphtheritic endocarditis, from the fact that the 
microscope reveals, in the tissue of the valves as well as 
in the thrombi, the presence of numerous colonies of mi- 
crococci, such as are also found within the multiple emboli 
which are so frequent in these cases. The organisms may 
be easily demonstrated by boiling the specimen in absolute 
alcohol and ether, and then examining it in glacial acetic 
acid. This form is more apt to be recurrent than pri- 
mary, and the ulceration may extend from its origin in the 
line of closure of the valves and involve the parietal en- 
docardium. There are, however, cases of acute ulcerative 
endocarditis which do not possess this malignant character ; 
ulceration in rare instances, for example, may be set up me- 
chanically by the repeated impinging of a cretified nodule on 
the aortic valve against the mitral curtain, the ventricular 
layer of which may be thus completely destroyed while the 
auricular layer is dilated in the form of an aneurism (acute 
valvular aneurism). This dilated portion may finally be- 
come perforated and the ulceration extend somewhat on the 
other side. (It is scarcely necessary to mention the fact that 
perforation of the valves may also take place in the malignant 
form.) Chronic valvular aneurism is found only in the left 
ventricle, and consists in a sacculation of all the layers of the 
valve, the convexity being always opposed to the blood-cur- 
rent — in the aortic valve toward the ventricle, in the mitral 
toward the auricle. The formation of thrombi may then give 



THE HEART. 131 

rise to secondary changes, and sudden death result from embo- 
lism of the carotid ; or else rupture may take place, and in- 
sufficiency be the result. Similar aneurismal dilatation occurs 
also in the upper part of the interventricular wall (septum 
fibrosum) and in the sinuses of Valsalva, particularly the 
right. 

Both papillary and ulcerative inflammation occur also on 
the chordae tendinear, which may be completely separated by 
the latter form, and thus incomplete valvular closure be 
brought about. 

There is a peculiar appearance which is sometimes met 
with in young children on the line of closure of the valves, 
called hematoma of the valves ; it consists in the presence 
of a number of small prominences, which sometimes occupy 
the whole circumference of the line of closure, and thus form 
a circle — the apices of which are dilated and contain small 
collections of blood. Fenestrated valves, semilunar valves 
with one or more defects between the line of closure and 
the free border, still retain their function unimpaired, and 
hence possess no special clinical interest. So also the oc- 
casional presence of four segments in the semilunar valves. 
In cases of valvular lesion a deposit of fibrine is often formed 
on the intact ventricular wall as well as on the diseased 
valves Qparietal thrombosis). Mechanical interference with 
the circulation may also give rise to this condition without 
the intervention of valvular lesion (marantic thrombosis). 
Hence it is especially liable to occur in the right heart, at 
the apex, between the trabecular and in the auricles, the 
points at which the circulation is least rapid. Such thrombi 
may be small and scarcely project above the surface of the 
trabecular, or they may be as large as or even larger than a 
cherry, and project boldly into the cavity (the globular veg- 
etations of Laennec) ; in the latter case they are usually firm 
and gray, or grayish-red at the periphery, and soft, reddish- 
gray, yellow, or brown at the centre. They are not to bo 
confounded with those firm and tough grayish-yellow masses 
of fibrine which are formed just before death, and can always 
be disentangled from the trabecular with comparative ease. 



132 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

(y.) The Commencement of the Aorta and the Coronary 
Arteries. 

The commencement of the aorta and the coronary arteries 
should be examined in connection with the heart. The in- 
tima of these vessels may present conditions similar to those 
of the valves in chronic endocarditis. Yellow irregular spots 
are due to fatty changes in the cells of the intima ; chronic 
inflammation of the intima (chronic deforming endarteritis) 
leads to local thickening or sclerosis, with which is associated 
cellular fatty degeneration and calcification. It is precisely 
this calcification of the patches of sclerosis within the coro- 
nary arteries which often causes considerable diminution in 
their calibre, and thus impairs the nutrition of the myo- 
cardium. The fatty change in the cells of the sclerosed 
patches may also involve the connective tissue, so that finally 
a cavity is formed containing a mixture of fat and choles- 
terine (atheromatous abscess), which may rupture inwards, 
and thus form an atheromatous ulcer. On and about this, 
fibrine may then be deposited, and a place of origin formed 
for embolism of other organs or parts. 

These changes in the intima are often associated with 
dilatation of the wall — aneurism. This condition, as well 
as a diminished calibre or hypoplasia, so often associated with 
chlorosis, etc., will be described in another place. 

Under congenital changes may be mentioned the tolerably 
frequent variations in the origin of the coronary arteries, 
which are sometimes given off high up on the aortic wall, 
instead of in the sinuses of Valsalva, or both may communi- 
cate with the aorta through the same opening. The ductus 
arteriosus sometimes remains open in adult life. 

8. THE LUNGS. 

To examine the lungs thoroughly they must first be re- 
moved from the thorax, but this must be done with great 
care, that the pulmonary tissue may be neither lacerated nor 
crushed. If extensive or old adhesions are present they are 
not to be torn through, but the costal pleura is also to be 



THE LUNGS. 133 

removed at these places according to the following method. 
A longitudinal incision is to be made in the costal pleura, 
and a finger of the right hand worked behind the lower 
edge of the cut along an intercostal space ; by a lateral move- 
ment of the finger and simultaneous traction inwards, space 
can generally be made for the hand, with the aid of which the 
detachment may be completed. In order to protect the back 
of the hand from being injured by the costal cartilages, which 
are very apt to be calcified in such cases, the external integ- 
ument should be folded over the cut ends, while the other 
hand draws them forcibly outwards. After the surface of 
the lungs has been freed from its attachments, the root of 
theleft lung should be included between the index and mid- 
dle fingers on the outer side, and the ring and little finger 
on the inner, drawn directly downwards, and divided care- 
fully. In removing the right lung the position of the fingers 
is, of course, reversed. 

(a.) The Pulmonary Pleura. 

The surface of the lungs should be again carefully exam- 
ined, after their removal from the body, with special refer- 
ence to the pleura and the presence of commencing inflam- 
matory exudation, which is indicated by a dull and opaque 
appearance of the normally smooth and glistening membrane ; 
this appearance can be brought out more distinctly by allow- 
ing the light to fall on the surface obliquely. In general, 
what has been already said with regard to the pericardium 
applies equally to the pleura, but affections of the latter are 
much more frequent, especially the eruption of gray, submil- 
iary nodules, — tubercles, — which may take place over a 
large surface, or be limited to the immediate vicinity of nod- 
ules within the lung. They may be conjoined with fresh, 
often hemorrhagic, inflammatory exudation, as well as with 
the results of chronic pleurisy ; in the latter case they are 
very often found in the fibrous adhesions. In chronic tuber- 
culosis, nodules of considerable size are often formed by the 
confluence of smaller ones, and they may become cheesy ; a 



134 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

favorite seat of these large cheesy masses is in the interlobular 
fissures. Cancerous nodules occur not unfrequently in con- 
nection with cancer of the breast. The pulmonary pleura is, 
more often than the pericardium, the seat of circumscribed 
necrosis, as indicated by a yellowish-gray discoloration, fria- 
bility, and softness; the lung tissue beneath such spots is 
generally ulcerated or gangrenous. It is a very interesting 
fact that these necrotic portions of the pleura always retain 
their smooth and reflecting surface — i. e., show no signs of 
inflammation, — although the whole surrounding membrane 
may be covered with a fibrinous deposit. Perforation may 
result from the process, the hole usually being from three to 
five millimeters in diameter, and a communication is thus es- 
tablished with the pulmonary lesion, which is usually a cav- 
ity. Certain peculiar changes in the appearance of the sur- 
face of the lungs are to be explained by the arrangement of 
the superficial lymphatic vessels, which, as is well known, lie 
between the lobules and form a subpleural network. These 
lymphatic vessels are subject to inflammatory changes of an 
acute as well as of a chronic nature ; the latter give rise to a 
thickening of the walls, especially at the points of anasto- 
mosis (pseudo-tubercle), and to a dilation of the vessels ; the 
presence of puriform material within the vessels (purulent 
pleural lymphangitis), is due to an acute process. This 
lymphangitis may be closely counterfeited by the presence of 
portions of a new formation within the vessels, as is not very 
rare in cancer of the stomach or breast, in lympho-sarcoma, 
etc. The vessels which contain the new formation appear as 
a network of whitish or gray bands, which are here and 
there interrupted by nodular masses of the growth, particu- 
larly at the points of anastomosis. When, as is often the 
case, the process starts from the root of the lung, the largest 
lymphatic vessels and the greatest number of nodules are 
found at and about that point, and gradually diminish in 
size and numbers as the periphery is approached. 



THE LUNGS. 135 

(b.) Special Examination of the Lungs from without. 

The examination of the pleura is followed by that of the 
various divisions of the lungs with reference to size, form, 
color, degree of distention with air, and consistency. 

1. The size of the lungs as a whole should have been noted 
before the heart was opened, but we are now enabled to ex- 
amine individual portions with especial reference to their 
mutual relations. As a basis of comparison it is well to take 
the size of the lungs in moderate expiration. Enlargement 
of one lobe is usually due to emphysema, pneumonia, or 
oedema ; diminution in the size of one lobe often results from 
compression by pleuritic exudation, which, if it has lasted a 
long time, may give rise to vicarious emphysema of another 
lobe. 

2. Alterations in form are either congenital — unusual 
fissures and increase in the number of the lobes — or ac- 
quired; the latter include those changes which are due to 
local cicatricial contraction of the pleura or lung itself, cir- 
cumscribed increase in size by emphysematous blebs, and cir- 
cumscribed diminution in size from collapse of the surface 
over pulmonary cavities of considerable size. Peculiar changes 
in form are sometimes brought about by a large pleuritic ef- 
fusion when small areas of the compressed lung are firmly at- 
tached to the chest-wall, the two being connected by long, 
nipple-shaped processes. 

3. The color of the surface varies with the age and occu- 
pation of the individual, as well as with the amount of blood 
and air which the organs contain. If the individual be of ad- 
vanced age or for any other reason have inhaled much coal- 
dust, the surface acquires a bluish-gray (slaty) or blackish 
discoloration, which appears first about the interlobular lym- 
phatic vessels, forming a network with dilatations at the 
points of anastomosis, but later extends to the bases of the 
lobules and becomes more uniform. It is not uncommon to 
find on the pleural surface of these carbonaceous lungs small 
grayish-white nodules which cover the points of anastomosis 



136 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

of the lymph vessels, and might easily be mistaken for tuber- 
cles ; they are in reality nothing more than local thickenings 
of the connective tissue of the pleura, due to the chronic ir- 
ritation. This slaty color, which is more or less marked in 
almost every adult, often masks completely the color of the 
pulmonar} 7 parenchyma, which varies between gray and red 
according to the amount of blood which it contains. Spots 
of atelectasis are easily recognized externally by their bluish- 
red color. A light brownish color, which is usually most 
marked in the upper lobes, owing to the comparative want of 
blood, depends on the presence of brownish or brownish-red 
pigment (hsematoicline), and occurs in passive pulmonary 
congestion — brown induration. The color of the surface 
may also be modified by an affection of the pulmonary pa- 
renchyma itself, and one must take care not to mistake 
small, cheesy nodules, the color of which is transmitted 
through the pleura, for tubercles in that membrane. 

4. The amount of air present in the lungs and their con- 
sistency are alike tested by the sense of touch. The lung 
which is normal in these respects is soft, easily compressible, 
and crepitates. Great softness and indistinct fluctuation in- 
dicate softening and the formation of cavities ; firmness and 
density with lack of crepitation indicate diminution or ab- 
sence of air. If a portion of lung, however, which presents 
the latter characteristics be at the same time of undimin- 
ished, or even of increased size as compared with neighbor- 
ing portions whose distention corresponds with that of mod- 
erate expiration, abnormal substances must be present in the 
air spaces. Relative diminution in size, on the other hand, 
points to atelectasis from compression or other cause. It is 
often of clinical interest in these cases to ascertain whether 
such portions were capable of inflation, or whether retraction 
of the pleura, or changes within the lungs, had rendered their 
distention impossible. This can be done by attempting to 
txlow up the affected portion artificially from one of the large 
bronchi, but the external examination should first be com- 
pleted. The same expedient may be resorted to in cases of 



THE LUNGS. 137 

pneumothorax when the perforation cannot be readily found. 
By immersing the lung in water and blowing air into it, the 
opening will be indicated by the stream of air-bubbles which 
escapes through it. The sensation produced by firm, hard 
nodules, varying in size from that of a millet grain to that of 
an apple, and enveloped in lung tissue containing air, is very 
characteristic : these nodules are generally the result of bron- 
chitis, peribronchitis, and slaty induration. Cavities give 
rise to a sensation of fluctuation or quivering, whether filled 
with air or fluid. 

The size of the alveoli can best be determined at the 
apices and edges of the lungs. The normal alveoli appear 
as minute vesicles, but when diseased may reach the size of 
the head of a pin, a millet-grain, a pea, or may be even 
larger in alveolar or vesicular emphysema. The tissue is 
then soft and rarefied to the touch (Rokitansky). Emphy- 
sema may be only local, and is then especially apt to appear 
in the form of blebs as large or larger than a cherry or wal- 
nut ; the small projecting ridges found on their inner sur- 
face show that the larger blebs result from the confluence of 
a number of smaller vesicles. 

There is still another variety of emphysema, — interstitial 
or interlobular emphysema, — which is brought about by the 
rupture of vesicles and the escape of air into the interlobular 
connective tissue, in consequence of obstructed expiration or 
the development of gas from decomposition. It is made evi- 
dent by the presence of air-bubbles of various sizes, arranged 
like the beads on a rosary, between the lobules and beneath 
the pleura, though it sometimes gives rise to an interlacing 
network resembling that described in connection with the 
lymphatic vessels. These bubbles of air can sometimes be 
displaced and moved about by pressure with the finger. 

(c.) Internal Examination of the Lungs. 

To examine the pulmonary parenchyma each lung in turn 
is to be placed on its diaphragmatic surface, its root so 
grasped in the left hand that the primary bronchus lies in 



138 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the fork between the thumb and forefinger, and is then laid 
open from top to bottom in such a way as to expose the 
largest possible surface : the incision should pass near the 
root so as to open the larger bronchi and vessels at the same 
time. The right middle lobe is to be laid open independently 
by a cut from behind forwards — its greatest diameter. Both 
the bronchi and vessels should then be followed up and 
opened with narrow scissors, one blade being probe-pointed, 
as much of the pulmonary tissue as possible being always 
included between the blades. If nothing of importance has 
thus far been detected it may not be necessary to carry the 
examination further ; if certain portions have already been 
recognized as the seats of local trouble, a number of smaller 
longitudinal cuts should be made through them. 

1. General Condition and Appearance. 

The amount of blood contained in the organ is indicated in 
part by the quantity which flows out over the cut surface 
from the vessels or can be squeezed out of them, but chiefly 
by the coloration of the tissue. A normal lung deprived of 
its blood is light gray, but the color varies according to the 
amount of blood present, from a bright brick-red (medium 
amount) to a dark, reddish-brown or purple. The color is 
also influenced by the amount of air contained in the lung. 
The brownish-red lung of a child which has never breathed, 
for example, changes to a bright brick-red when blown up 
artificially, and vice versa, a portion of the lung of an adult 
may be dark in color from imperfect expansion with air, and 
consequent limitation of the usual blood supply to an area 
smaller than that which it normally occupies. The blood 
supply is not the only factor in modifications of the normal 
color of the lungs. Carbonaceous pigment is present in the 
lungs of almost every adult, varying in quantity according to 
the mode of life, and produces a bluish-gray or slaty appear- 
ance, as has already been mentioned in connection with the 
pleura. The higher degrees of this condition are called an- 
thracosis, and, when evidence of chronic inflammation is 



THE LUNGS. 139 

superadded, anthracopneumonoeoniosis. A similar discolora- 
tion may also depend on the presence of metamorphosed 
blood-pigment, — haematoidine ; and this form occurs almost 
invariably in connection with those chronic inflammatory 
processes which accompany pulmonary consumption (slaty 
induration). There is also a brown discoloration from meta- 
morphosed blood-pigment (brown induration), which is found 
in connection with certain cardiac lesions. While the first 
two forms are generally confined to the newly formed con- 
nective tissue, or to the normal interlobular bands, the lat- 
ter is very apt to extend also to the cells which lie free in 
the alveoli as well as to those which line the alveolar walls. 
These cells are easily obtained for microscopical examination 
by simply scraping the cut surface, while to examine the 
yellow or yellowish-brown pigment contained in the connec- 
tive tissue (also largely contained in its cells), a small fold 
of pulmonary tissue must be raised with forceps, snipped 
off with fine scissors, and somewhat teased apart in water. 
The alveolar capillaries are also found to be of unusual size 
and to project into and encroach upon the air spaces, thus 
producing a general diminution in the air contained in these 
lungs, as well as an increased firmness and density. 

2. Special Morbid Conditions. 

(a.) Of the Parenchyma and Smallest Bronchi. 

The alveoli constitute the most important part of the 
parenchyma, and are to be examined with reference to their 
degree of distention with air and the presence of abnormal 
contents. 

(a.) Alveolar or vesicular Emphysema, as has been al- 
ready mentioned, causes apparent dilatation of the alveoli, 
but in reality the abnormally large air-spaces result from 
atrophy and subsequent rupture of the partition walls ; the 
capillaries are thus destroyed also, and emphysematous por- 
tions have consequently a pale and anaemic appearance. 
Emphysema may be widely diffused or limited to small 
areas, and in the latter case is usually vicarious ; it is almost 



140 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

always associated with bronchial catarrh and bronchiec- 
tasis. 

(6.) Atelectasis, absence of air and consequent collapse of 
the alveoli, may originate in four different ways. In foetal 
atelectasis, which may be either limited to single lobules or 
extend over considerable areas, air has never entered the af- 
fected portions. Atelectasis from compression is due to pres- 
sure from without, is usually quite extensive, and depends 
commonly on chronic inflammatory pleuritic effusion. In this 
form the blood-vessels are very apt to be compressed also, and 
the affected portions hence acquire a dirty-grayish appearance ; 
while in simple collapse of the lungs, on the other hand, the 
affected portions seem to contain even more than the normal 
amount of blood. Thirdly, atelectasis may depend on plug- 
ging of a bronchus, in which case, the vessels not being com- 
pressed in any way, the affected portions are dark-red or 
purple in color. This form always occurs in wedge-shaped 
masses, the apices of which are directed toward the bronchus, 
and the bases of which lie, as a rule, at the surface of the 
lung. Atelectatic portions of lung, whatever their mode of 
origin may be, are always diminished in size, and are hence 
always depressed below the level of the surrounding normal 
tissue. Lobular atelectasis has a very characteristic appear- 
ance and, inasmuch as it is the result of capillary bronchitis, 
is an important diagnostic sign of that affection. Partial 
atelectasis, finally, may be the result of great prostration, 
and feebleness of the respiration, — marantic atelectasis, — 
in which case it always occupies the posterior and inferior 
portions of the lungs ; the blood also settles into these por- 
tions (hence the term hypostasis) which become greatly con- 
gested and very dark- red in color. In these cases, as well as 
in those in which atelectasis is due to compression, the alveoli 
are very apt to be subsequently filled with the fluid of oedema, 
which causes the shrunken portions to swell up, and converts 
them finally into soft bluish-red masses, devoid of air and 
resembling the spleen, — hence splenization. When the 
oedema is very marked, it may, in turn, compress the blood- 



THE LUNGS. 141 

vessels, and the affected portions then acquire a gelatinous 
appearance like frog's spawn — the gelatinous pneumonia of 
Laennec. 

We are naturally led to consider next those conditions of 
the alveoli in which, though deprived to a greater or less 
degree of their air, they are not collapsed, but are filled witli 
abnormal matters. The cut surface of portions thus affected 
varies in color, consistency, and character, according to the 
character of the alveolar contents ; and on the accurate ob- 
servation of these three points depends, therefore, the differ- 
ential diagnosis. 

(c.) The simplest of these conditions is pulmonary oedema, 
the presence of a clear, watery fluid within the alveoli, 
whether throughout the lung or only in limited portions of it. 
The tissue still contains more or less air, but is heavier, denser 
than normal, has often a peculiar translucent appearance, 
and pours out from its cut surface spontaneously, though in 
larger quantities on pressure, a fluid containing small air- 
bubbles and more or less tinged with blood. The presence 
of these small air-bubbles in extensive oedema is a sign that 
the condition was established during life, while the absence 
of air-bubbles indicates that it did not take place till after 
death (a very common occurrence in the lower lobes). That 
form of oedema which is sometimes found in normal portions 
of diseased lungs is known as collateral oedema, and may 
be the direct cause of death in spite of "its limited distribu- 
tion. 

(d.) Haemorrhage. The alveoli may be filled with blood ; 
the most remarkable form of this condition is that known 
as hemorrhagic infarction, found in connection with val- 
vular lesions of the left heart (especially mitral lesions), 
and depending on rupture of the vessels from increased 
pressure in the pulmonary circuit. It is possible that rup- 
ture may also be brought about by fatty degeneration of 
the intima consequent on dilatation, and the pulmonary ar- 
tery should, therefore, always be examined. A hemorrhag- 
ic infarction is always pyramidal in shape, with its base at 



142 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the surface and its apex directed inwards ; it varies in size, 
is sharply circumscribed, of great density, very dark-red in 
color, and usually projects, under the pleura, somewhat above 
the level of the surrounding tissue. As is readily seen from 
the exterior, its borders always coincide accurately with those 
of the lobules, and it is never limited to a portion of a lobule 
but involves invariably the whole. On section, the affected 
portion is seen to be very dark-red or almost black, and is 
distinguished from a very similar condition, which is of in- 
flammatory origin and will presently be described, by its 
clearly defined pyramidal shape, its nearly smooth and but 
very faintly granular surface, from which a certain quantity 
of fluid blood can usually be scraped, its great density, and 
its localization at the periphery. A plugged artery can often 
be found at the centre of the mass — secondary thrombosis. 
When the contents of the alveoli are examined microscopic- 
ally in a solution of common salt, they are seen to consist of 
the usual constituents of coagulated blood, quantitatively as 
well as qualitatively. Sections can easily be made with the 
double knife and show that the alveoli are not only filled, 
but distended with blood, while the capillaries, from being 
thus compressed, are often entirely empty. The subse- 
quent changes undergone by a hemorrhagic infarction de- 
pend on this latter circumstance. The affected portion be- 
comes practically a foreign body, and is separated from the 
surrounding parts by purulent circumscribed inflammation. 
The softened mass is then seen to be surrounded by a nar- 
row yellow line which, in its turn, is limited by a zone of 
redness gradually disappearing toward the periphery. Pro- 
gressive suppuration may thus completely detach the mass 
from the adjoining tissue and leave it in a cavity which may 
cicatrize and heal up after its contents have been discharged. 
The course of affairs is not always, however, so favorable ; 
the blood may decompose and thus set up circumscribed gan- 
grene, in which the compressed and bloodless tissue within the 
infarction naturally becomes involved, so that finally a cavity 
filled with greenish-brown and highly offensive fluid is formed, 



THE LUNGS. 143 

from the inner wall of which the remains of the pulmonary- 
tissue hang in shreds. Such a gangrenous cavity is usually 
surrounded by inflamed tissue, — fibrinous inflammation, — 
which when widely extended may eventually prove fatal. 
Pleurisy is almost invariably associated with pulmonary gan- 
grene, and, when the gangrenous spot extends as far as the 
pleural surface, is very apt to be of a putrid character. 

The decomposed masses are shown by the microscope to 
be of a highly composite character, and are remarkable 
for containing elastic fibres from the alveoli. The pres- 
ence of these fibres is, as is well known, of great diagnostic 
value during life, and their detection may be facilitated by 
the addition of dilute caustic soda. Immense numbers of 
bacteria of spherical as well as rod-like form, crystallized 
fatty acids, fat drops, etc., are always present; and these 
constituents are often combined in the form of small whitish 
bodies of the most offensive character. The oidium albi- 
cans is also sometimes found here. 

Embolic infarction, the result of the plugging of a branch 
of the pulmonary artery, resembles the hemorrhagic variety 
very closely, and cannot, indeed, always be distinguished 
from it. These infarctions are also peripheral as a rule, but 
instead of being sharply defined are merged gradually into 
the surrounding healthy tissue, and- are seldom of consider- 
able size, for the reason that partial plugging of the larger 
branches never gives rise to infarction, while complete plug- 
ging of such branches is rapidly fatal. Complete plugging 
of the smaller branches is not, moreover, necessarily followed 
by the formation of an infarction, as is well seen in cases of 
multiple emboli, some of which have led to infarction, while 
others have not. Embolic infarction, pure and simple, oc- 
curs only when the emboli are derived from a bland throm- 
bus, and exert a purely mechanical influence ; if, on the other 
hand, the emboli contain septic material, then the periph- 
eral infarctions are associated with small abscesses (em- 
bolic pneumonia'), though the latter may alone be present, 
and occupy the periphery or the centre of the lung indiffer- 



144 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

ently. Or the two may be combined in such a way that an 
abscess occupies the centre of the mass, while the periphery 
is infiltrated with blood. Septic emboli are usually so brit- 
tle that their resulting infarctions are small. A peculiar but 
apparently pretty common condition in cases of injury to the 
brain, and particularly to the pons and medulla oblongata, 
consists in haemorrhage (usually in the form of infiltration) 
and oedema. These two conditions are often, indeed, so 
closely associated that, in unilateral injuries to the above- 
named portions of the brain, sometimes only the lung of the 
same side is found to be the seat of change (vagus). 

(e.) Inflammation. Those forms of inflammation in which 
the air of the alveoli is replaced by inflammatory products 
are the most important, and may be divided into two classes : 
1st, cellular pneumonia, in which the inflammatory product 
is chiefly cellular ; and, 2d, fibrinous pneumonia, in which it 
is chiefly composed of fibrine. 

1. Fibrinous pneumonia usually affects a whole or the 
greater part of a lobe, and is always diffuse, or, in other 
words, the transition from the normal tissue to the point of 
maximum intensity is always gradual. The appearances 
vary according to the stage which the process has reached. 
The first stage, that of engorgement, in which the lung be- 
comes dark-red from great congestion of the vessels, cannot, 
of course, be diagnosticated as such, for the reason that we 
cannot know with certainty what the result of the hyperae- 
mia might have been ; it is only when infiltration has begun, 
or hyperemia is found in a part contiguous to an already ex- 
istent infiltration, that we can properly speak of the initial 
stage of the inflammation. In the second stage, the affected 
portion is enlarged, heavy, and resistent, and its cut surface 
has a grayish, or dark-red, and coarsely granular appearance ; 
the latter characteristic is more clearly brought out by scrap- 
ing the cut surface firmly with the edge of the knife, and 
thus squeezing out of the alveoli solid plugs, which are suffi- 
ciently large to be recognized by the naked eye, and are 
shown by the microscope to be casts of one or more of the 



THE LUNGS. 145 

alveoli. These plugs, as is readily seen in sections of the 
tissue, occupy all the alveoli without exception, and, as their 
color would indicate, consist chiefly (not entirely, as in hsem- 
orrhagic infarction) of blood, and also of a large amount of 
fibrine, and some colorless cells. The coarsely granular char- 
acter of the cut surface permits us to distinguish pneumonia 
from hemorrhagic infarction without the aid of the micro- 
scope, and it depends on this richness in fibrine. From the 
resemblance in consistency which the inflamed lung bears 
to the liver, the condition has been termed red hepatiza- 
tion. 

This is followed by yellow hepatization, the only gross 
distinction between which and the red variety is the color ; 
but the microscope shows that the blood has disappeared, 
and is replaced by great numbers of small lymphoid and 
larger epithelioid cells, which latter have been derived from 
proliferation of the alveolar epithelium. The vessels have 
been compressed by the exudation, and the lung is therefore 
anaemic. Lungs which contain large quantities of black pig- 
ment are gray rather than yellow in this stage (gray hep- 
atization) . 

The fourth and last stage is that of resolution, in which 
the density gradually diminishes, the cut surface loses its 
granular character, and the color becomes more distinctly 
yellow. A tenacious, opaque, and grayish-yellow fluid can 
now be squeezed out from the cut surface in large quantities, 
and is found, on microscopical examination, to consist of 
fatty degenerated cells, and a viscid fluid into which the 
fibrine has been converted. The pulmonary tissue is often so 
soft in this stage that in removing the lungs from the body 
portions lying under the pleura may be crushed and disor- 
ganized ; cavities thus arise which become filled with a puri- 
form fluid and may be mistaken for abscesses. It sometimes 
happens, however, that genuine abscesses are formed from 
undue participation of the connective tissue in the inflamma- 
tory process. A more common result is diffuse gangrene of 
the lung, a condition which may also depend on antecedent 
10 



146 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

bronchiectasis and putrid bronchitis, or occasionally on a 
strongly marked haeroorrhagie character of the inflammation. 
Diffuse gangrene may resemble the circumscribed form in 
every respect, except in sharpness of definition. 

Fibrinous pneumonia is found with greater frequency in 
the lower than in the upper lobes, and progresses upwards, so 
that the several stages are often coexistent and portray the 
course of the affection. The hepatized portions are always 
the seat of collateral oedema, which is very apt to be found in 
the healthy lung in unilateral pneumonia also. 

Fibrinous pneumonia is almost invariably associated with 
fibrinous pleurisy, as is indicated by the old term pleuro- 
pneumonia, which, however, is not quite appropriate, inasmuch 
as both catarrhal and cheesy pneumonia are very often asso- 
ciated with pleurisy, and might hence be included under the 
term. Cases also sometimes occur in which this order of 
things is reversed and a primary pleurisy gives rise to fibrin- 
ous pneumonia in the adjoining tissue. The inflammation 
may extend to the bronchi too, and then set up either fibrin- 
ous bronchitis with the formation of grayish-white casts or 
masses of fibrin e within the tubes, or simple bronchitis, with 
redness and swelling of the mucous membrane and increased 
secretion. As a rare event fibrinous pneumonia becomes 
chronic in character. Instead of undergoing resolution the 
affected portion is converted into a dense, airless, uniformly 
red and fleshy mass — carnification. The microscope shows 
that the alveoli are replaced by vascular connective tissue 
into which, as in the organization of thrombi, the inflamma- 
tory alveolar contents have been converted. 

The second class — cellular pneumonia — may be again 
subdivided into pneumonia with soft, partly fluid and partly 
cellular, exudation, and pneumonia with firm and dry exuda- 
tion. To the former subdivision belongs — 

2. Catarrhal pneumonia, or broncho-pneumonia, as it may 
often be called, for the reason that the parenchymatous affec- 
tion is secondary to that of the finer bronchi. This form of 
pneumonia is generally lobular, and, even when of consid- 



THE LUNGS. 147 

erable extent, is not in its earlier stages distributed uniformly 
through the tissue, but appears in the form of numerous 
small gray or grayish-yellow spots embedded in reddened 
lung substance; these represent minute foci of pneumonia 
limited to the region of the smallest bronchial tubes, — true 
broncho-pneumonia. When the process is extremely acute, as 
well as in its later stages, the tissue may be uniformly infil- 
trated throughout; in this case the cut surface is of a grayish 
color, is smooth or at the most finely granular, and pours out 
from the alveoli on pressure large quantities of a gray, opaque 
fluid which contains no air. The microscope shows this fluid 
to contain great numbers of small, round, and some epithe- 
lial cells. 

Chronic catarrhal pneumonia is a very common affection, 
and has a very characteristic appearance ; it may either be 
confined within narrow limits, or, in a more extensive form, 
may complicate other chronic inflammatory affections. The 
tissue which is the seat of this process is devoid of air, oedem- 
atous, of a general grayish color, but sprinkled with minute 
light yellow spots, and pours out on pressure a highly albu- 
minous, tolerably clear fluid, in which are suspended minute 
yellow punctate bodies. These bodies are shown by the 
microscope to be fatty degenerated catarrhal cells, — gran- 
ular corpuscles, — which are sometimes so large that a single 
one of them forms the whole minute speck which is vis- 
ible to the naked eye. Rindfleisch holds that the above de- 
scribed condition is not to be regarded as the final stage of 
catarrhal inflammation, but is the result of atelectasis to 
which oedema has been superadded — persistent (inveterirtes) 
oedema. There is another inflammatory affection of the lungs 
which occupies a somewhat peculiar position. I refer to that 
form of pneumonia which is met with chiefly in the insane 
and is due to the inhalation of particles of food. It originates 
as broncho-pneumonia, but the exciting cause is such that de- 
composition is very liable to set in, and even diffuse gangrene 
sometimes ensues. Solid particles of foreign substances gen- 
erally find their way into the lower lobes when drawn into 



148 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the lungs, and the lower lobes are consequently the chief 
seats of this form of pneumonia as well as of those forms 
which depend on the inhalation of portions of diphtheritic, 
cancerous, or other masses from the throat or upper air pas- 



The differences between the fibrinous and catarrhal forms 
of pneumonia are much less marked in childhood than in 
adult life. In consequence of the greater activity of cellular 
growth, and particularly of the larger size of the alveolar 
epithelium in children, the exudation is seldom purely fibrin- 
ous, but contains great numbers of cells, especially of the 
epithelioid variety. The cut surface is not granular but 
smooth, and grayish-red rather than dark-red, for the reason 
that the haemorrhagic element is almost entirely wanting. 
The two forms can nevertheless be distinguished from each 
other by the character of the exudation, which in the fibrin- 
ous form still contains sufficient fibrin e to render the alveolar 
contents firm and cohesive. 

White hepatization, so called, originates during foetal life 
and is always the result of syphilis. The lungs are dense, 
devoid of air, and of a whitish appearance ; and the micro- 
scope shows the epithelial cells of the alveoli and small 
bronchi to be fatty degenerated. 

3. Contrasted with these soft, cellular forms of pneumonia 
is the hard form, which, from the character of the change 
undergone by its products, may be called cheesy pneumonia. 
Like the fibrinous variety it has several stages, which are dis- 
tinguished by the color they impart to the cut surface. In 
the first stage it is of a red color, not the dark-red of the 
fibrino-haemorrhagic form, but of a lighter, more grayish-red, 
which later becomes grayish-yellow, and finally yellow. The 
two latter stages are those of caseation, the progress of which 
is always attended by increasing yellowness. 

This form of pneumonia is characterized in all its stages 
by dryness of the cut surface, density, and, at least in the 
earlier stages, by a finely granular appearance, each granule 
corresponding with a collection of cells in an alveolus. When 



THE LUNGS. 149 

the alveolar contents are placed under the microscope they 
are seen to be of a somewhat different composition from 
those of catarrhal pneumonia, consisting chiefly of large epi- 
thelioid cells closely aggregated together — old and young 
desquamated epithelium ; the process has hence been called 
desquamative pneumonia. According to Virchow the later 
developments of the process are due chiefly to the distention 
of the alveoli, while Buhl and Rindfleisch lay more stress on 
the condition of the interstitial tissue, in which they always 
find collections of large and thickly aggregated cells (tuber- 
cular inflammation of Rindfleisch). The cellular growth is 
indeed so active both within the alveoli and in their walls 
that the blood-vessels are compressed, and the cells then 
undergo a species of fatty degeneration or caseation. The 
microscope shows that caseation is not a pure fatty degenera- 
tion, but that the cells lose their water and shrivel also. 

Cheesy pneumonia, like the catarrhal variety, sometimes 
appears in the form of broncho-pneumonia, and is generally 
lobular, or, in other words, involves uniformly whole lobules ; 
it is not infrequently, however, met with in the form of small 
disseminated nodules, — miliary cheesy pneumonia, — some- 
times extends uninterruptedly over large areas, and, in rare 
cases, indeed, over entire lobes, then constituting the most 
acute form of what has been termed galloping consumption. 
Nodules of cheesy pneumonia are distinguished from those of 
bronchitis and peri-bronchitis, which we shall describe in an- 
other place, chiefly by their finely granular cut surface. 

4. Metastatic pneumonia, to which we alluded in connec- 
tion with embolic infarction, has some peculiarities worthy of 
mention. It usually occurs in the form of multiple peripheral 
nodules lying immediately beneath the pleura, terminating in 
abscesses which are often foetid or gangrenous, and sometimes 
contain at their centre a softened mass of necrotic material 
which may be more or less detached by suppuration. Al- 
though the origin of the nodules and abscesses cannot always 
be demonstrated as embolic, it is such without exception, and 
the emboli are furthermore always of a malignant or septic 



150 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

character, and so soft and pliable that the local irritation to 
which they give rise never results in changes of great extent, 
the part affected being rarely larger than a cherry. Inflam- 
mation of the pleura is always set up by these abscesses, and 
this inflammation is often likewise of a septic or malignant 
character, and attended with foul exudation. Septic pleurisy 
may, indeed, be the sole indication leading us to suspect 
metastatic processes in the lungs, and should always induce 
us to institute careful search for such processes whenever its 
presence cannot be readily accounted for in any other way. 
As is always the case in septic suppuration, the cells become 
destroyed with great readiness, and the fluid when examined 
microscopically is found to contain little more than broken 
down pus cells, detritus, and often large masses of micro- 
cocci. 

5. We have now reached the last class of the inflamma- 
tory affections of the pulmonary parenchyma, interstitial 
pneumonia, the primary seat of which is the interstitial or 
interlobular connective tissue. 

Acute suppurative interstitial pneumonia is rather rare ; 
one variety of it we have already mentioned as an unusual 
complication of some cases of fibrinous pneumonia. In 
cases of empyema we sometimes find yellow bands of sup- 
puration which start from the surface of the pleura, extend 
inwards along the septa, and in the interior may be connected 
with one another, and follow the course of the bronchi and 
vessels. There is generally no difficulty in ascertaining that 
the pus is contained in spaces with smooth walls, the course 
and distribution of which is such that they must be lymphatic 
vessels, and the process, therefore, is a suppurative lymphan- 
gitis. 

Chronic interstitial pneumonia, or cirrhosis of the lung, is 
a far more common affection, and results in fibrous thicken- 
ing of the septa. The pulmonary tissue, which may or may 
not be involved in the inflammation, is seen to be traversed 
by narrow bands of connective tissue, which may gradually 
compress it more and more, finally converting it into dense 



THE LUNGS. 151 

fibrous masses. Large quantities of black pigment derived 
from the blood are always deposited in these places — slaty 
induration, — and show them to have been the seat of an 
acute process at one time. Chronic interstitial pneumonia, 
pure and simple, is always suggestive of syphilis, but is rather 
rare. It is far more apt to be associated with other chronic 
and sometimes cheesy conditions of the parenchyma and 
bronchi, and then represents a sort of cure of these processes. 
This form occurs chiefly in the apices, and may completely 
surround small cheesy or calcified nodules ; retraction of the 
upper part of the chest results, as is also evident from clini- 
cal experience. 

6. Peribronchitis, inflammation of the connective tissue 
surrounding the bronchi, is sometimes an affection of great 
importance. In the form of acute suppurative peribronchitis, 
it is rather rare and occurs only in connection with very 
rapid phthisis. It is far more common in the chronic forms 
of fibrous and cheesy peribronchitis, and is then manifested on 
section by great numbers of small, round, and closely aggre- 
gated nodules which may easily be, and indeed often are, mis- 
taken for tubercles ; these really represent cross sections of 
clusters of minute bronchial tubes close to their junction with 
larger branches. On careful inspection a minute dark point 
may sometimes be seen at the centre of each of these nodules 
— the open end of the tube — but this is not always the 
case, since the tubes may be either obliterated or completely 
plugged with cheesy material. The lung substance which 
intervenes between these nodules of peribronchitis is very 
often the seat of slaty induration, and the lung then contains 
hard masses of the size of a walnut or larger, which can 
be felt from the outside, and consist of dense slate-colored 
fibrous tissue in which the gray or yellow peribronchitic nod- 
ules of the size of a pin's head or millet seed are imbedded. 
The affection does not remain stationary but continues to 
progress, and it is consequently at the edge of the slaty por- 
tions that we find the most typical peribronchitic nodules. 

7. It is our purpose in this place to touch on inflammation 



152 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

of the smaller bronchi, bronchitis, or better, bronchiolitis, 
only as far as it is directly connected with inflammation of 
the parenchyma. Thus limited it is always essentially a 
chronic process. In connection with peribronchitis it has al- 
ready been mentioned that fibrous bronchitis causes obliter- 
ation of the smaller tubes. Cheesy bronchitis is an affection 
of greater importance, the products of catarrhal inflamma- 
tion remaining within the tubes, and there undergoing case- 
ation. Cheesy inflammation of the larger bronchi is easily 
recognized, and can be demonstrated by cutting the tubes 
open with scissors ; when the same affection involves the 
smaller bronchi and, as happens so often, is associated with 
fibrous peribronchitis, it may easily be mistaken for tubercu- 
losis on account of the strong resemblance which the nodules 
with yellow, cheesy centres and gray, fibrous circumferences 
(encysted tubercle of the older authors) bear to old tuber- 
cular deposits which have become cheesy. They can always 
be recognized as belonging to the bronchi by their arrange- 
ment in clusters. 

(/.) Tubercles are found in the lungs in three forms 
which differ essentially from one another. 

1. The simplest, and at the same time the rarest form is 
disseminated tuberculosis, which is but part of a general or 
widely distributed process and is characterized by the presence 
of minute gray nodules which are scattered pretty uniformly 
through the tissue, but which, especially in the upper lobes, 
may be of large size, yellow at the centre, and gray and 
translucent at the periphery. The smaller miliary tubercles 
in particular often project like little spheres above the level 
of the cut surface and can be easily isolated from their con- 
nections. The diagnosis is decidedly strengthened when the 
nodules are found along the blood-vessels also, in the terri- 
tory of the lymphatic vessels which accompany them. The 
large nodules to which we have already referred are usually 
in part the result of a desquamative pneumonia which is set 
up by and surrounds the tubercles. 

2. Localized tuberculosis may be further subdivided into 



THE LUNGS. 353 

two forms, the first of which may retain the term localized 
tuberculosis, though in a narrower sense, and bears a similar 
relation to the lungs as the disseminated form to the body in 
general. It is characterized by the development of single tu- 
bercles about a cheesy nodule or cheesy ulceration in the lung 
as well as about the bronchial glands. The tubercles are gen- 
erally surrounded by normal pulmonary tissue, are apt to be 
more closely aggregated, larger, and further advanced in 
caseation immediately about the cheesy centre, and to become 
more scattered, smaller, and younger as we recede from that 
point. This resembles the disseminated form also in being 
more commonly met with in children than in adults. 

The second subdivision of localized tuberculosis in its 
broader signification is characterized by the deposition of tu- 
bercles in inflamed pulmonary tissue, near and in the midst 
of the inflammatory products. The forms of inflammation 
which are thus complicated are cheesy pneumonia and peri- 
bronchitis, those forms which are especially prone to result 
in destruction of tissue. To adopt a nomenclature analogous 
to that which is employed with reference to serous mem- 
branes, this form may be termed tubercular inflammation of 
the lungs. Of all the forms it is the most difficult of recog- 
nition ; it may, indeed, be said that it is generally impossi- 
ble to decide in any given case without the aid of the micro- 
scope, whether the pulmonary disorganization is of a purely 
inflammatory or of a tubercular inflammatory nature. As 
one would naturally expect, but little is to be gained by even 
microscopic examination of a fresh specimen, for a knotty 
point like this can be solved in only the thinnest and most 
delicate sections. It is pretty safe to assume, however, in 
most cases that the affection is not purely inflammatory, 
but of a mixed or tubercular and inflammatory character, 
even when the pathological changes must be ascribed in 
great measure to true inflammatory processes. 

3. The third and last variety of pulmonary tuberculosis is 
tubercular inflammation of the bronchial tubes, particularly 
of the smaller ones — bronchitis tuberculosa. In very re- 



154 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

cent cases, the tubercles usually appear to the naked eye as 
very minute dots or points in the bronchial mucous mem- 
brane and are more likely to occur in the upper lobes. They 
almost never attain considerable size, and least of all, become 
cheesy, for the reason that they are very prone to break down 
rapidly and to leave superficial ulcerations with everted edges 
and grayish-yellow bases. If the mucous membrane is in- 
flamed and reddened the ulcers are easily recognized ; but 
if, on the other hand, it is pale and anaemic, then recognition 
is often attended with great difficulty. In the latter case 
they can sometimes be brought to view by rubbing a little 
blood gently over the surface ; the blood adheres to their 
edges and thus renders them easier of recognition. The 
ulcers increase both in size and depth by the constant forma- 
tion and breaking down of fresh tubercles, and may finally 
perforate the bronchial wall and involve the surrounding 
pulmonary tissue, which is generally more or less inflamed. 

(</.) To complete our sketch of these latter processes, all 
of which are very intimately connected with pulmonary con- 
sumption or phthisis, we will next take up the chronic for- 
mation of cavities in the lungs. 

1. Dilatation of the bronchi or bronchiectasis may be 
either pretty widely distributed and uniform (cylindrical 
ectasis), or limited to small areas and without uniformity 
(saccular ectasis). It may again be vicarious or secondary, 
when for any reason contiguous bronchi have become imper- 
vious to air, or it may result simply from chronic bronchitis. 
The dilated tubes are eve^where lined with mucous mem- 
brane, which retains its ciliated epithelium unimpaired. In 
the saccular form, especially, the secretions are very often re- 
tained, become decomposed, and set up inflammation (putrid 
bronchitis) ; or else inflammation follows inspissation and 
caseation of the secretion. These dilatations are also a favor- 
ite seat of the above described tubercular ulcers, which soon 
transform the dilated bronchi into ulcerating cavities. 

2. Cavities or vomica; may also be formed by the breaking 
down of pulmonary substance which has become the seat of 



THE LUNGS. 155 

the above mentioned cheesy processes. Such cavities may 
be completely closed and contain a soft mixture of pus and 
cheesy material, or they may be in direct communication with 
a bronchus through which their secretion is emptied ; the 
fact that such a communication exists does not in itself prove 
that the cavity is the result of bronchiectasis, for the reason 
that a cavity which increases in size must sooner or later be- 
come connected with one or more of the larger bronchi. It is 
only by the presence or absence of a mucous membrane that 
we can determine the nature of these cavities. If a com- 
municating bronchial tube can be followed up for some dis- 
tance along the inner wall of the cavity, or if traces of mu- 
cous membrane are found here and there within it, bronchial 
dilatation must have been present at this place at some time ; 
if such, however, is not the case, it is impossible to make a 
differential diagnosis from the local condition alone. Smooth- 
ness of the inner wall of the cavity proves nothing, of course, 
when taken alone, since a pulmonary cavity, the result of 
ulceration, may become perfectly smooth after the ulcerative 
process is arrested, but can still be distinguished from sim- 
ple bronchiectasis by the absence of a lining of ciliated epi- 
thelium. 

Several contiguous cavities may be gradually united into 
one, and thus form an irregularly scolloped cavity, the origin 
of which is betrayed by the persistence of portions of the 
septa. 

The only component parts of the lungs which show much 
resistance to destructive processes are the branches of the 
pulmonary artery, which often traverse cavities in the form 
of rounded cords, or project prominently from their inner 
walls and are still pervious to the blood-stream. The wall 
which lies toward the cavity is sometimes the seat of aneu- 
rysmal dilatation, when it is greatly weakened, and may rup- 
ture and give rise to fatal haemorrhage. The vessels which 
traverse cavities sometimes eventually break down after 
thrombosis has taken place within them, and leave only 
small, hard, grayish stumps or prominences projecting from 



156 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the wall. The presence of these prominences on the inner 
wall of a cavity may be regarded as proof positive that such a 
cavity — at all events in its present condition — is the result 
of ulceration. The appearance of the walls varies according 
to the condition which they may happen to be in. If the de- 
structive process has been progressing actively they seem to 
be formed of yellow, cheesy, and broken down masses, which 
often contain tubercles. We also meet with cases which have 
run a very rapid course where cavities are found filled with 
larger or smaller portions of lung tissue, which have been 
cut off from the circulation, have become cheesy, and are al- 
most completely detached from the wall ; if the process has 
become stationary, the walls are formed of dense fibrous 
tissue, the surface of which may be of a bluish-gray color 
or covered with granulations. Cavities occasionally become 
closed, contract, and heal completely, but this is by no means 
the rule. 

We have now described all the processes which are com- 
prised in what is generally known as pulmonary consumption, 
or phthisis. It would be a great mistake to suppose that any 
one of these processes singly brings about all the changes 
which are found in a case of phthisis ; as a rule several or 
many processes are coexistent, and this accounts for the great 
variety of appearance in phthisical lungs, of which scarcely 
any two are to be found alike. For this reason we cannot 
undertake to describe the manifold appearances to which 
combinations of the processes may give rise, but hope that 
what has been already said will enable the reader to distin- 
guish the several processes from one another, and thus un- 
derstand their sum. We would only repeat that many cases 
which at first were of a purely inflammatory nature are sub- 
sequently complicated with tuberculosis, which also takes its 
part in the destruction of tissue. The condition receives its 
name from the process which may happen to be predominant, 
and we speak of inflammatory or pneumonic phthisis when 
inflammation and caseation are chiefly prominent, or of tuber- 
cular phthisis when the reverse of this is the case. 



THE LUNGS. 157 

It should be mentioned, in conclusion, that cheesy masses, 
whether in the bronchi or in excavations of the pulmonary- 
tissue, may become in a measure harmless through calcifi- 
cation ; they become first thick and gritty, then grow gradu- 
ally harder and more stony until they form concretions 
known as pulmonary and bronchial calculi. On the other 
hand the destruction of tissue may be greatly hastened if 
putrefaction takes place in and about the collections of cheesy 
material — gangrenous phthisis. The cavity then contains 
dirty greenish-yellow necrotic material instead of cheesy pus, 
and its walls are ragged and gangrenous. 

(A.) Tumors are not uncommonly found in the lungs, and, 
although almost any form may be primary here, they are gen- 
erally the result of contiguity (as in cancer of the breast), or 
else of metastatis (mammary, gastric, oesophageal cancer, 
sarcoma of the neck or glands, etc.). We have already 
described the characteristics of the various forms of new 
growths, but one should take care not to mistake the normal 
pulmonary alveoli, which often persist toward the edges of 
the tumor, for the alveoli of cancer. By adding dilute caustic 
soda or potash to the microscopic specimen, the elastic fibres 
and their peculiar arrangement may be clearly brought out, 
and thus error avoided. 

There are a few manifestations to which tumors some- 
times give rise in the lungs, which are so peculiar as to de- 
serve special mention. All the forms of cancer are, in these 
organs, peculiarly prone to break down, and may form cavi- 
ties communicating with a bronchus or with each other, very 
similar to those which result from cheesy pneumonia. An 
ulcerative destruction of the lungs may be thus brought 
about, and has been justly termed cancerous phthisis. A 
second peculiar manifestation is that which is due to cancer- 
ous, sarcomatous, etc., lymphangitis. The tissue is traversed 
by narrow bands of the morbid growth, with dilatations or 
nodules at the points of anastomosis, very much as in super- 
ficial, or subpleural, and deep, or parenchymatous, purulent 
lymphangitis. This form is chiefly met with in connection 



158 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

with cancer of the breast and stomach, lymphosarcoma of the 
cervical glands, etc. Careful examination of the contents of 
the lymphatic vessels with the microscope will generally 
throw light on the nature of the process, though the under- 
taking is not always an easy one. 

(X) Echinococci are sometimes found, and may give rise 
to the formation of abscess and perforation : their characteris- 
tics were described in sufficient detail in connection with the 
brain. 

((3.) Morbid Conditions of the Larger Bronchi. 

Although the bronchial affections, and tubercular bron- 
chitis in particular, of which we have already spoken on 
account of their intimate connection with parenchymatous 
changes, are also met with in the larger bronchi, these latter 
are more commonly the seat of independent processes, chiefly 
of an inflammatory nature — catarrhal and purulent bron- 
chitis. The catarrhal form is manifested by swelling and 
redness of the mucous membrane and increase in its secre- 
tion ; the purulent form by more intense redness and swell- 
ing, and gray or yellowish- white muco-purulent, or light yel- 
low purulent secretions, which may be poured out in such 
quantities as to completely fill the larger tubes. In both 
forms alike the mucous membrane is always infiltrated with 
small cells. It is a serious matter when the purulent form 
attacks the smallest tubes — capillary bronchitis — as is so 
commonly the case in children, the practical result being 
very like that of pneumonia. These very small tubes cannot 
be followed up and laid open with scissors, and one must 
therefore get at the character of their contents by squeezing 
them out from the cut surface. Minute drops of pus well- 
ing up at a certain distance from one another on pressure, in- 
dicate the presence of capillary bronchitis. The connection 
between this form of inflammation and lobular atelectasis has 
been already alluded to. 

Chronic catarrhal bronchitis, such as is usually associated 
with emphysema, and, as has been already mentioned, is so 
often the cause of bronchiectasis, leads to considerable thick- 



THE LUNGS. 159 

ening of the mucous membranes ; the transverse and longi- 
tudinal fibrous strias are brought out with great prominence, 
especially at the bifurcations, where they may give rise to 
actual stenosis. The portions of the wall which intervene 
between these projecting fibrous bands sometimes become 
bulged out and form minute diverticula. 

In those cases in which fibrinous or croupous bronchitis oc- 
curs independently of fibrinous or croupous pneumonia, it is 
generally secondary to laryngeal croup. The larger bronchi 
are found to be lined with a pretty dense, fibrinous false mem- 
brane, sometimes as much as two millimeters in thickness, 
which forms complete hollow casts of the tubes, and can be 
removed from them as such. Cases of uncomplicated fibrin- 
ous bronchitis are very rare, and usually run a chronic course. 

Tumors are very rarely primary in the bronchi. Small 
ecchondroses, or simple outgrowths from the cartilaginous 
rings, sometimes occur, and when metastatic deposits are 
very abundant in the lungs they are also sometimes found in 
the bronchial mucous membrane. 

(y.) The Pulmonary Vessels. 

The vessels are the only important parts of the lungs 
which still await our consideration. Some of the changes 
which they undergo have been already alluded to, as brown 
induration, the result of dilatation of the capillaries, the 
larger branches, and even the main trunk of the pulmonary 
artery sometimes, in consequence of passive congestion de- 
pendent on valvular disease of the left heart ; fatty degener- 
ation of the intima is also to be sought for, a condition which 
predisposes to hemorrhagic infarction, and is manifested by 
the presence of irregularly-shaped yellow spots, or even small 
losses of substance, on the inner surface of the arteries. 
Then emboli which may escape demonstration, but give rise 
to embolic infarction and metastatic abscess ; likewise aneu- 
risms which are sometimes formed in cavities in the lung, 
and on bursting may give rise to fatal haemorrhage. Some- 
thing still remains to be said, however, about emboli, of the 
larger branches of the pulmonary artery in particular, which 



160 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

neither give rise to infarction nor abscess. An embolus 
sometimes rides, as it were, on a point of bifurcation, extend- 
ing only a moderate distance into either branch, and does not 
completely stop the circulation. In such a case it may pass 
through its various stages, and give rise to no very great dis- 
turbance. It loses its color gradually from without inwards, 
becomes dryer, firmer, smaller, and adherent to the wall ; 
eventually it is reduced to a dense and firmly attached sub- 
stance, which may be colored reddish or ochre-yellow by has- 
matoidine. On tearing a bit apart with needles, and placing 
it under the microscope, the pigment will be found either in 
the form of masses or of crystalline rhombic plates or prisms. 
If, on the other hand, the embolus blocks a larger vessel com- 
pletely, life is usually of short duration ; and if the vessel be 
relatively small, the portion of tissue which is thus cut off 
from the arterial circulation may become gangrenous, secon- 
darily to gangrene of the infarction caused by the embolus. 
Emboli have sometimes undergone decolorization and other 
changes at the seat of their formation, before they have got 
into the lungs, hence before they have become adherent to 
the wall of the pulmonary vessel. 

In searching for the origin of a pulmonary embolus the 
right heart should first be examined, particularly its auricular 
appendage, and the depressions between the trabecule of 
the ventricle. If the place of origin cannot be found there, 
it must be sought in the veins, and, above all, in the veins 
of the lower extremities, and in the periprostatic, periuter- 
ine, and perivaginal plexuses of the pelvis. In recent cases, 
a correspondence in character between the pulmonary emboli 
and the thrombi in a particular part, render it probable that 
the former were derived from the latter. 

There is another species of embolism of the pulmonary 
arteries and capillaries — fat embolism — which occurs in al- 
most every case of extensive fracture of the bones, and can- 
not be demonstrated without the aid of the microscope. It 
is only necessary to remove a small bit of the lung with 
scissors, and spread it out in water, in order to see that the 



THE COSTAL PLEURA. 161 

capillaries, and even rather larger vessels, are more or less 
extensively filled with glistening and highly refractive masses 
of fat. 

(8) The Bronchial Lymphatic Glands. 

These glands present many pathological conditions, which 
may be either primary or secondary to changes in the lungs. 
They are almost always more or less pigmented, sometimes so 
much so that a black fluid resembling ink may be squeezed 
from the cut surface. This pigmentation generally corre- 
sponds in degree with that of the pulmonary tissue, though 
it is usually rather more intense. 

Almost all inflammatory processes in the lungs are com- 
plicated with redness, swelling, and softening of these glands, 
from the cut surface of which considerable fluid is poured 
out ; in phthisis the glands are almost invariably more or 
less cheesy, and often contain gray nodules, isolated as well 
as in groups at the circumference, which are readily rec- 
ognized as tubercles. Sometimes, however, particularly in 
children, the cheesy or scrofulous condition of the glands is 
evidently of longer standing than that in the lungs, and may 
be completely wanting in the latter. Cheesy masses in the 
bronchial glands are much more frequently calcified than 
in the lungs, and entire glands, with the exception of the 
thickened fibrous capsules, may become thus altered. 

Sarcomatous and cancerous changes also occur in this situ- 
ation ; the former usually, and the latter always, being sec- 
ondary. The bronchial glands are a favorite seat of lympho- 
sarcoma (pseudo-leucoBmia, Hodgkin's Disease). 

9. THE COSTAL PLEURA AND THE POSTERIOR PORTIONS 
OF THE RIBS. 

As a rule, it is unnecessary to pursue the examination of 
the costal pleura further, and in some cases it is removed 
and examined together with the lung. This, as we have al- 
ready mentioned, is to be done when there are very exten- 
sive adhesions ; and it is desirable to do so in cases of chronic 
fibrinous and purulent pleurisy, for the reason that the size 
11 



162 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

of the sac, the effects of the process on the lung itself, etc., 
are thus more easily seen. The corresponding half of the 
diaphragm should also be removed, together with the lung 
in these cases, and, for this purpose, it is better to em- 
ploy scissors, as involving less risk of injury to the adjoining 
abdominal viscera. 

The pathological conditions of the two layers of the pleura 
are, of course, essentially the same, but each present cer- 
tain peculiarities from the fact that the relations of the two 
layers are not identical. For instance, cancer of the breast, 
when it extends inwards, usually attacks the costal before 
the pulmonary pleura ; as do also inflammation, ulceration, 
and perforation, in caries and fracture of the ribs, and in 
external wounds. Miliary tubercles sometimes present pe- 
culiarities of distribution on the costal layer. They are 
often much more thickly aggregated in the intercostal spaces 
than over the ribs ; collections of cheesy material, such as 
are often found in chronic tuberculosis, also occupy the inter- 
costal spaces as a rule. More or less subserous fatty tissue is 
normally present in these situations, and may become much 
increased, and form long, narrow, intercostal lipomata. Old 
pleuritic false membranes, and particularly the thickened 
costal layer, are often the seat of extensive calcification, and 
contain smooth and nodular plates resembling bone in hard- 
ness. Small lymphatic glands, from the size of a hempseed 
to that of a pea, are sometimes found in the costal pleura, 
and are congenital ; they are occasionally long and pendu- 
lous, with narrow necks. 

The posterior portions of the ribs may be examined to- 
gether with the costal pleura. 

10. THE OBGANS IN THE NECK. 

(a.") Method of Examination, 
The Regulations (§ 20) laid down for medical jurists, in 

examining the neck, should be followed in all cases, and 

direct as follows : — 

" The neck may be examined either before or after open- 



THE ORGANS IN THE NECK. 163 

ing the chest and removing the lungs, according to the pe- 
culiarities of each individual case. It is the duty of the 
examiner to investigate the condition of the larynx and air 
passages by themselves whenever special importance is at- 
tached to them, as in cases of drowning or hanging. 

"As a rule, it is desirable to examine the great vessels and 
nerve trunks first, and then to open the' larynx and trachea 
from before, and note their contents, if any. The last indi- 
cation is best fulfilled by exerting careful pressure on the 
lungs while in situ ; any abnormal fluids, etc., will thus be 
squeezed out, and their character easily determined." 

In cases of injury to the larynx or trachea, and whenever 
important changes are suspected in them, the air passages 
should be first removed, together with the other organs of the 
neck, and opened afterwards. The best method to pursue is 
the following : The knife is passed through into the mouth 
at the left angle of the jaw close to the inner surface of the 
bone and carried round as far as the right angle, being kept 
close to the bone all the time. Near the chin the handle of 
the knife should be depressed, to prevent the point from 
piercing the tongue instead of merely severing the attach- 
ment of the genio-glossus muscle. After the tongue has 
been completely freed from the lower jaw it is to be drawn 
downwards with the left hand, while with the knife in the 
other hand the attachments of the soft to the hard palate 
are divided. The posterior wall of the pharynx is then to 
be divided as high up as possible, and the knife is passed 
round either tonsil, then by firm traction on the tongue, the 
pharynx and oesophagus are detached from the vertebral 
column and the deep muscles of the neck. On reaching the 
chest the vessels of the upper extremities are to be divided 
on either side by a cut directed outwards and backwards from 
the sternal end of the clavicle ; the oesophagus and bronchi 
may then either be cut across above the arch of the aorta or, 
if it be not desired to examine the latter separately in its 
whole course, it may be detached from the vertebral column 
also, and together with the oesophagus cut across just above 



164 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the diaphragm. This latter method should be pursued 
whenever an important affection of the cesophagus is sus- 
pected, and sometimes in cases of poisoning and of cancer 
of the cardiac orifice it is well to remove the stomach and 
oesophagus entire. 

In all cases in which it either is, or may be, of importance 
to determine the effects of disease in the organs of the neck 
and chest whether deep seated or more superficial, especially 
the heart and lungs, it is better to preserve their mutual con- 
nection as far as possible and to remove all the organs of 
the neck and chest together ; after their topography has 
been accurately noted they can then be examined in detail. 

(5.) The Individual Parts or Organs. 
(1.) The Great Vessels and Nerves of the Neck. 

(a.') Next to rupture of the intima of the carotids, which 
acquires medico-legal importance from its occurrence in cases 
of hanging, the most important morbid condition which is 
found in the vessels of the ?iecJc, particularly in the carotids 
by reason of their contributing so largely to the blood sup- 
ply of the brain, is narrowing and obliteration of their 
calibre. Narrowing depends on chronic inflammation and 
calcification of the intima, like that which occurs on the 
valves of the heart ; obliteration is due to large emboli which 
sometimes turn out to be the unsuspected cause of sudden 
death. Among the morbid conditions of the veins dilata- 
tion may be mentioned, such as is often found in connection 
with heart disease, or aneurism of the aortic arch, and throm- 
bo-phlebitis of the upper portion of the internal jugular vein, 
dependent on inflammatory thrombosis of the transverse 
sinus. 

(6.) The cervical sympathetic nervous system, and partic- 
ularly the three ganglia, the middle of which is often want- 
ing, are of special interest. The superior of these is usually 
selected for examination on account of its larger size and 
easier isolation ; it lies near the transverse processes of the 



THE ORGANS IN THE NECK. 165 

second and third cervical vertebrae, on the deep muscles of 
the neck, and behind the internal carotid and vagus, which 
may serve as guides. 

Most of the changes found in these ganglia proceed from 
their vessels ; haemorrhage, in the various diseases which are 
accompanied by delirium and sunstroke ; varicose dilatation 
of the vessels in unilateral hyperidrosis. The nerve fibres 
of Remak have further been found in a condition of fatty 
degeneration in diseases attended with hectic and in pneu- 
monia with marked delirium, and the ganglion cells are ab- 
normally pigmented in all cachexias. 

Haemorrhage has also been found in the vagus in hsemor- 
rhagic small-pox, and in sunstroke (Koster) ; secondary 
changes, chiefly of an atrophic nature, may be produced 
by tumors, etc., in the neighborhood. Inasmuch as the 
pressure exerted by tumors, aneurisms, etc., on the lar- 
yngeal branches of the vagus, often results in important 
changes within the larynx (paralysis and fatty degeneration 
of its various muscles), it is sometimes interesting to follow 
the course of these branches. The superior laryngeal nerve 
runs down to the larynx along the inner side of the carotid 
artery and divides into two branches, the inner of which 
pierces the hyo-thyroid membrane in company with the lar- 
yngeal artery, while the outer ramifies in the muscles outside 
of the larynx. The inferior or recurrent laryngeal nerve is 
longer on the left than on the right side ; it passes back 
round the subclavian artery on the right side, the arch of 
the aorta on the left, and runs upwards on both sides alike 
between the trachea and oesophagus to supply the muscles 
within the larynx. 

(2.) The Mouth and the Pharynx. 

To examine the mouth and pharynx the soft palate may 
either be cut through at the side of the uvula, or, if it is not 
important to preserve the connections of the left tonsil with 
external neighboring parts, outside the tonsil ; a clear view 
having been thus obtained of the mucous membrane of the 



166 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

soft palate and its relations to the tonsils, the latter may- 
then be laid open longitudinally. 

The color of the palatal and pharyngeal mucous membrane 
varies between a pale gray, a bright red, and a dark purple 
(death from suffocation, etc.). The darker shades of color are 
apt to be associated with more or less swelling, which may, 
however, exist in connection with a somewhat yellowish 
tinge (oedema). Both redness and swelling generally dimin- 
ish decidedly after death. 

Stenosis of the isthmus of the fauces or of the nasopharyn- 
geal cavity by bands of cicatricial tissue is usually due to 
syphilis, the scars resulting from which are notoriously 
prone to great contraction. Radiating cicatrices of limited 
extent are often seen on the surface of the tonsils and re- 
duce them more or less in size. 

Wounds of the edges of the tongue near the teeth are often 
inflicted during spasms, particularly of an epileptic nature, 
and, when found after death, may throw great light on the 
preceding symptoms. 

The most important changes found in the mucous mem- 
brane of the mouth and pharynx are due to inflammation in 
its various forms. 

Acute catarrhal inflammation is characterized by marked 
injection and swelling of the mucous membrane with a coat- 
ing of thick, tenacious mucus, and is often accompanied by 
considerable swelling of the follicles. In the higher degrees 
of inflammation the mucus is replaced by thick grayish-yel- 
low pus. In chronic catarrhal inflammation the most prom- 
inent changes are those of the follicles — granular pharyn- 
gitis. The tonsils participate in these conditions, are swollen, 
and their crypts are full of a soft, yellowish, puriform ma- 
terial, which is shown by the microscope to be composed of 
desquamated epithelium, mucus, and fatty detritus. In the 
chronic forms this secretion is much more dense, often more 
or less slate-colored, and the crypts contain offensive yellow- 
ish-gray plugs, which may be more or less calcified. The 
follicles at the base of the tongue are also swollen. 



THE ORGANS IN THE NECK. 167 

The affections known as croup and diphtheritis represent 
still higher degrees of inflammation. The term croup being 
originally of purely clinical significance, misunderstanding 
will best be avoided by applying the adjective fibrinous to 
that form of inflammation which is characterized by the exu- 
dation of a coagulable albuminous material on the surface of 
the mucous membrane, forming a continuous and easily de- 
tachable membrane. It must not be thought, however, that 
the process involves absolutely no change in the mucous 
membrane itself. On the contrary, after removal of the 
false membrane, the mucous coat appears intensely red and 
swollen, often containing numerous haemorrhages, and — as is 
readily seen in fresh sections with the double knife when 
placed under the microscope and made clear with acetic acid — 
is always infiltrated with .cells, even in its deeper layers. 
This form of inflammation occurs on the palate and pharynx, 
and the false membranes, which are easily detached without 
injury to the true and underlying membrane, are often found 
on the posterior surface of the palate, on the uvula, and above 
all in the sinus pyriformes. It is by no means rare to find 
at the same time in other situations, and particularly on the 
tonsils, that species of inflammation which is known as diph- 
theritic. This may be either primary or secondary (in variola, 
scarlatina, etc.), and is characterized by the formation of a 
false membrane which not only covers the mucous surface 
but is also firmly adherent to it and extends more or less 
deeply into its substance. The underlying mucous mem- 
brane is infiltrated with fibrine and granular matter as well 
as with cells, and thus easily becomes necrotic ; recovery is 
then only possible through separation of the slough and cica- 
trization of the open surfaces which remain behind. A fresh 
yellowish-gray diphtheritic deposit may be formed over these 
open surfaces, constituting what are known as diphtheritic 
ulcers. 

To ascertain the depth of the diphtheritic infiltration inci- 
sions must be made in different portions of the affected parts. 
The microscope shows invariably the presence of great mini- 



168 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

bers of low organisms, the most common of which are nests 
of micrococci ; these are very often of a brownish shade, 
especially under low powers, and may occupy the mucous 
membrane itself as well as the diphtheritic deposit, as is well 
seen on the addition of glacial acetic acid or very dilute 
caustic potash. When colonies of micrococci have been often 
seen, they are not likely to be confounded with detritus or 
granular matter, and he who affirms the contrary has either 
never examined a case of diphtheritis, or else is unfit to use 
the microscope at all. The parasitic nature of the granules 
can be clearly demonstrated by boiling the specimen first 
in glacial acetic acid, then in a mixture of equal parts of 
absolute alcohol and ether, finally examining it in glacial 
acetic acid and glycerine. In purely fibrinous membranes 
they are by no means constant, needle preparations showing 
an albuminous substance which becomes swollen in acetic 
acid and is infiltrated with a variable number of cells. 

Mucous membrane which is the seat of the diphtheritic 
process is often very prone to break down, become gan- 
grenous, grayish-green in color and ragged, with a most of- 
fensive smell : these are the cases which present the most 
marked changes in the pharynx and fauces, and in which the 
swelling reaches its highest pitch. 

There is another form of inflammation which is not super- 
ficial, but attacks the deeper layers of the mucous membrane, 
and, especially the submucous tissue, and which from its re- 
semblance to phlegmonous inflammation of the external in- 
tegument may be called suppurative sore throat (angina 
phlegmonosa) . The tonsils are the favorite seat of this form 
(though it occurs also elsewhere in the throat) and may be- 
come so swollen as to exceed a pigeon's egg in size. In the 
earlier stages of the affection the interstices of the tissue are 
filled with an opaque, grayish-yellow fluid containing large 
numbers of pus cells ; while in the later stages the fluid be- 
comes even more opaque and yellow — i. e. more purulent, — 
and may form abscesses, especially in the tonsils, which 
empty outwards. This form of inflammation may be of an 
infective character, as in malignant pustule, erysipelas, etc. 



THE ORGANS IN THE NECK. 169 

The changes which are brought about by syphilis and 
tuberculosis next demand our consideration. That early 
manifestation of syphilis to which the term mucous patch has 
been applied is naturally not often met with in the corpse ; 
but when found is covered with a grayish secretion resem- 
bling that of the chancre. As a rule we find only the cica- 
trices resulting from these patches, which, as we have already 
mentioned, give rise to stenosis and other deformity of the 
parts. A cicatricial condition is often found at the base of 
the tongue, and, if present, may prove of material assistance 
in diagnosis. When the base of the tongue is found to be 
flattened and depressed, to have lost its follicles, and its 
mucous membrane is thickened and grayish-white in color, it 
is highly probable that we have to deal with the results of 
syphilis. The muscular substance of the tongue may be the 
seat of yellow gummy nodules as well as of the cicatrices 
which they occasionally leave behind them. Perforation of 
the hard palate, whether large or small, is almost sure to be 
due to syphilis, provided only that the congenital condition 
known as cleft palate can be excluded. 

Tubercular affections of the mouth and pharynx are less 
common than the syphilitic, though they are met with in the 
form of miliary tubercles, as well as in the form of tubercu- 
lar ulceration. The character of the latter is betrayed by 
its uneven edges, and the presence of small cheesy, or recent 
and gray nodules, both on the base and edges. The adjoin- 
ing tissue is sometimes considerably hypertrophied, thus 
causing papillary elevation of the edges of the ulcer. Tu- 
bercular ulcerations as well as disseminated tubercles are 
occasionally found in and upon the tongue in the course of 
the lymphatic vessels. 

Lupus and leprosy belong to the same group of tumors as 
gummata and tubercles, and the same forms appear in the 
buccal mucous membrane as in the external integument. 
Lupus, especially, may on cicatrization give rise to groat 
deformity. 

Cystic tumors occur in various portions of the mouth ; the 



170 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

most common of these is ranula, which is seated under the 
tongue alongside the fraBnum, and is due to a plug in the 
duct of the submaxillary gland and the resulting retention 
of secretion. The tongue is subject to a very peculiar hy- 
pertrophy — macroglossia — due to enlargement of its lymph 
spaces and vessels. Epithelioma of the tongue, in common 
with the two affections mentioned, comes rather within the 
domain of surgery; it starts from those portions of the 
tongue which are in contact with the teeth, and spreads both 
backwards and forwards, often very widely. The tonsils 
are sometimes the seat of the soft varieties of cancer. 

The appearances of thrush in the mouth and pharynx are 
the same as in the oesophagus, in connection with which they 
will be described. 

(3.) The (Esophagus. 

The organs of the neck should be so placed in examining 
the oesophagus, that the latter lies uppermost, and it may 
then be opened with scissors along its left border (to the 
right of the operator). 

(a.) General Morbid Conditions. The oesophagus may 
be either dilated or contracted. Dilatation may be either 
general or local, the former being usually due to stenosis 
lower down in the intestinal canal; its wall, and particu- 
larly the muscular layer, is very apt to become hypertrophied 
at the same time. A relaxed condition of the muscular coat 
may simulate dilatation, but the naccidity of the muscle, and 
the absence of any other cause of widening, will generally 
reveal its true nature. Local dilatation is found above a 
contraction, whether the latter is caused by tumors or by 
cicatricial tissue. The forms we have thus far considered 
involve the whole circumference of the tube ; limited por- 
tions, however, may be involved, and thus arise what are 
known as diverticula. These may attain considerable size, 
and are usually seated between the oesophagus and vertebral 
column. 

Contractions or stenoses are almost always local, resulting 



THE (ESOPHAGUS. 171 

from cicatricial tissue or cancerous growths, and occur chiefly 
on a level with the cricoid cartilage or the bifurcation of 
the trachea ; the tube may be contracted without being ac- 
tually diseased, as for instance, below a marked stenosis. 

The color of the mucous membrane is almost always a pale 
gray, but may be yellowish from contact with icteric con- 
tents of the stomach. Hyperemia of the pharynx, however 
marked, very rarely extends into the oesophagus. Thicken- 
ing of the epithelial coat renders the surface whiter ; the post- 
mortem action of the contents of the stomach on the lower 
portions renders them brown and soft — brown softening. 

(b.) Special Morbid Conditions. We need not dwell long 
on inflammation of the oesophagus. Simple inflammation is 
associated with abundant desquamation of the epithelium ; 
the fibrinous and diphtheritic forms are rare, though they 
sometimes occur, especially in scarlatina and haemorrhagic 
small-pox. The latter forms bear a strong resemblance to 
thrush. 

The oesophagus is not unfrequently the seat of injury, 
from the accidental or intentional introduction of hard bodies 
(among which bougies may be included) or corrosive liquids. 
The latter are especially important from their frequent use 
as poisons. Sometimes they leave only slight traces from 
the rapidity of their passage, but they may give rise to ex- 
tensive alterations. When the mucous membrane is acted 
on mildly by acids, it presents a grayish or yellowish discolor- 
ation, and is hard and wrinkled ; the action of alkalies causes 
it to become softened and to present a brownish discolora- 
tion resembling post-mortem softening, but differing from 
that condition by its action on test-paper. Both acids and 
alkalies, when very concentrated, corrode the tissue, and color 
it brown or black. In cases in which life is more or less pro- 
longed, the eschars may come away with suppuration, and 
cicatricial tissue be formed ; this contracts over a larger or 
smaller surface, producing a varying degree of stenosis. 

Under tumors we will mention the occasional occurrence 
of a varicose condition of the veins, especially in the lower 



172 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

portion, and phlebolites. The lipomata, myomata, and 
fibromata are rare in this situation ; but cancer is quite 
frequent, and from mechanical causes is very apt to occupy 
that portion of the oesophagus which crosses the left primary 
bronchus. It is generally of the epithelial variety, soon 
ulcerates, and may finally lead to perforation into the trachea, 
pleura, pericardium, etc. Congenital cesophago-tracheal fis- 
tulas are sometimes met with. 

The parasitic affection known as thrush (mycosis o'idica) 
occurs in the oesophagus, and derives most of its importance 
from the fact that it may easily be mistaken for inflamma- 
tion attended by the formation of a false membrane, particu- 
larly of the fibrinous variety. This affection, which may also 
occur in the pharynx, is found chiefly in cachectic adults, 
and in children who are ill-nourished and fed from the bot- 
tle ; it gives rise to the formation of a soft whitish mem- 
brane, which is easily stripped off the mucous surface, and 
often closely resembles a fibrinous false membrane, but is 
distinguished by its softness. Needle preparations, how- 
ever, when placed under the microscope, show that it is com- 
posed of the superficial layers of the epithelium covering 
the mucous surface, and of great numbers of fine, thread- 
like, jointed formations (oidium albicans), from which elon- 
gated conidia have become freely detached. 

(4.) The Larynx and Trachea. 

To lay open these parts the organs of the neck are placed 
in the same position as in opening the oesophagus, and, after 
inspection of the position of the vocal cords from above, the 
posterior wall is cut through with scissors along the median 
line, where the cartilaginous rings are defective ; the cut 
edge of the oesophagus, on the left, should, meanwhile, be 
drawn out of the way, toward the left of the operator. The 
organs are then to be laid on the fingers of both hands, and 
the interior of the larynx brought clearly into view by 
spreading it open with the thumbs, one being placed on each 
corner of the thyroid cartilage. If the cartilages are ossi- 



THE ORGANS IN THE NECK. 173 

fied, they must be forced apart, even if they are broken in 
the process. 

The morbid conditions of the larynx and trachea are, in 
the main, identical with those of the mouth and pharynx, 
which we have already described. 

A very important condition, to which children are espec- 
ially liable, is oedematous swelling of the mucous membrane 
of the cords and ary-epiglottic folds — oedema of the glottis. 
It should never be forgotten that oedema is always much less 
marked after death than during life ; a degree of swelling 
which involved danger to life may, indeed, have almost en- 
tirely disappeared when the section is made. The degree of 
tension of the mucous membrane may be of considerable 
value in this connection. If, instead of being smooth and 
even, it lies in folds and wrinkles, we can be sure that oedema 
has been present. (Edema is almost invariably of inflam- 
matory origin, and is very seldom really primary in the 
larynx, but is secondary either to affections of the larynx and 
pharynx, or to erysipelatous or phlegmonous inflammation of 
the face. 

Modifications in form. Unimportant changes in the form 
of the trachea may be brought about by pressure from with- 
out, calcification of the cartilaginous rings, cicatrices, etc., 
and sometimes the tube is thus flattened like a scabbard. A 
very remarkable condition, however, is that known as the 
suffocative position of the epiglottis. The surface of this 
organ is normally but very slightly curved from side to side, 
but in all forms of death from suffocation its edges are found 
to be more or less approximated, in extreme cases producing 
a wedge-shaped appearance. 

The color and amount of blood in the upper air pas- 
sages are of great interest to the medical expert, who gains 
information from the intensity of a green or greenish-brown 
discoloration as to the time at which death took place, and 
from the presence of a bluish tinge as to the cause of 
death (suffocation). The caution which we enjoined with 
regard to oedema applies equally here ; the color and degree 



174 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

of injection after death may convey but a very imperfect idea 
of the condition of things during life. Quite commonly, 
particularly in children, the trifling changes which are found 
in the mucous membrane of the larynx in general, and of the 
vocal cords in particular, afford no adequate explanation of 
the violent symptoms which preceded death. 

Although the simple superficial fibrinous inflammations are 
less common in the mouth and pharynx than the diphthe- 
ritic inflammation with infiltration, the reverse is the case 
in the larynx and trachea. Tubular casts of the interior of 
these latter parts are common enough, and small isolated 
patches of false membrane are still more common. The 
membranes vary greatly in thickness ; the more delicate often 
present to the naked eye a reticulated appearance even, 
which is yet more distinct under the microscope. This pe- 
culiar appearance is due to the secretion of the mucous 
glands, with the duct of one of which each individual de- 
pression in the false membrane corresponds. 

Fibrinous false membranes sometimes extend continuously 
far into the bronchial tubes, and retain the same character 
throughout, but, as a rule, they become thinner, and more 
broken as they enter the lung, being gradually merged into 
a simply catarrhal muco-purulent secretion. The pulmonary 
parenchyma itself is sometimes involved, but the resulting 
pneumonia, instead of being fibrinous, as the ill-chosen term 
croupous would lead one to expect, is always and without 
exception of the catarrhal form. 

Diphtheritic affections of the larynx and trachea, though 
more rare, are not uncommon. These parts, as well as the 
epiglottis, are sometimes the seat of a false membrane which 
can be detached only with the greatest difficulty, and the 
underlying mucous membrane presents a grayish infiltration. 
The parts of the trachea which are more commonly the seat of 
this affection are those adjoining the wound of tracheotomy. 
Those forms of inflammation in the larynx and trachea 
which complicate many infectious diseases, and particularly 
the acute exanthemata, often acquire a diphtheritic charac- 



THE ORGANS IN THE NECK. 175 

ter. In variola small diphtheritic patches are often found in 
the trachea — chiefly over the cartilaginous rings — and have 
been erroneously supposed to be the peculiar eruption of that 
disease. Pneumonia, very often of a malignant type, and in- 
volving rapid destruction of tissue, is sometimes set up by 
the inhalation of particles of diphtheritic material from the 
pharynx as well as from the larynx and trachea. 

We need only allude to the fact that phlegmonous inflam- 
mation may extend from the pharynx to the entrance of the 
larynx. That oedema of the glottis may thus be caused has 
already been mentioned. 

Chronic inflammation is very common, and varies in appear- 
ance according to its intensity and duration. A trifling de- 
gree of the condition is often found in those whose occupation 
involves more or less strain of the vocal organs (singers, etc.), 
and is manifested by a bluish-white discoloration, and thick- 
ening of the vocal cords, especially their posterior portions. 
The thickening and discoloration are almost wholly due to a 
moderately tough membrane-like substance, which can be 
easily stripped off the mucous membrane with forceps, leaving 
it quite intact, and when placed under the microscope is seen 
to consist of epithelial cells, which have become decidedly 
horny. The condition is, therefore, a simple thickening of the 
epithelial layer ; a sort of pachyderma. In higher degrees of 
the process the mucous membrane itself, both that covering the 
cords as well as that lining the cavity, is thickened, of a 
grayish- white shade, and denser than normal. This condi- 
tion is sometimes found in children after prolonged whoop- 
ing-cough. The mucous glands share actively in chronic 
catarrh ; they are enlarged, their ducts are dilated, and act- 
ual cysts sometimes result from them. 

Ulceration in its various forms is very common, of great 
importance when found in the larynx, and is generally due to 
phthisis, typhoid fever, or syphilis. Syphilitic ulceration is 
most common in the edges of the epiglottis, which may be- 
come extensively destroyed, but it also occurs in the larynx, 
and, more rarely still, in the trachea. It is characterized by 



176 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

a yellowish, lardaceous appearance of the base and a rounded 
protrusion of the edges, the mucous membrane over which is 
often the seat of polypoid formations. The favorite seat of 
tubercular and typhoid ulceration is near the posterior attach- 
ment of the vocal cords, and both forms not infrequently at- 
tack the cartilage. According to Rokitansky, the typhoid 
ulceration is the result of gangrene, and has discolored gan- 
grenous edges ; while the edges of tubercular ulcers are 
always uneven, more or less scalloped, and of a yellowish 
color, like their bases. Tubercular ulcers are not confined 
to this limited locality, but may be found anywhere from 
the top of the epiglottis to the interior of the trachea. They 
are often, particularly on the epiglottis, so superficial, and, 
in common with the surrounding mucous membrane, so pale, 
as to be scarcely distinguishable ; sometimes, the mucous 
membrane at their edges is much thickened, like that around 
syphilitic ulcers. 

Ulceration, particularly when seated on the cords, is very 
often associated with purulent inflammation of the peri- 
chondrium of the arytenoid cartilages (perichondritis arytce- 
noidea), which may, however, also occur without ulceration, — 
in phlegmonous laryngitis, for instance. The perichondrium 
is separated from the cartilage by pus, and the latter is thus 
cut off more or less from the circulation, and becomes ne- 
crotic. The abscess generally breaks, without much delay, 
into the larynx, and leaves an opening of greater or less 
size communicating with a cavity within which the necrotic 
cartilage lies loose. If the process still persists, the arytenoid 
cartilage becomes detached in whole or in part, — may be got- 
ten rid of, a cavity the size of a cherry-stone being left in 
its place. Sometimes the inflammation extends to the cri- 
coid cartilage, and runs the same course there. 

Tracheal ulcers are chiefly tubercular, and may be very 
small and indistinct, or very extensive and confluent. Deep 
ulceration leads occasionally to perichondritis of the carti- 
laginous rings, one or more of which may become necrotic in 
whole or in part, and lie exposed at the base, or project from 
the edge of the ulcer. 



THE ORGANS IN THE NECK. 177 

The tubercular ulcers of the larynx and trachea are often 
associated with miliary tubercles, although the latter may 
be present without the former, particularly in the trachea ; 
these bodies are here usually extremely minute, gray, and 
translucent. The appearance of miliary tuberculosis may 
be exactly counterfeited in cases of simple catarrh, in which 
the mucous glands are involved, if the glands are compressed 
in forcing open the parts after the longitudinal incision has 
been made ; a minute gray drop, consisting chiefly of cast-off 
epithelium, is thus forced out of the duct of each gland, but 
the condition is easily distinguished from tuberculosis as the 
drops disappear when the finger is passed lightly over the 
surface of the mucous membrane. Cicatrices resulting from 
old ulceration are found in the larynx and trachea — par- 
ticularly in the former, as is the case with the pharynx, — 
and generally point to syphilis, especially if the cicatricial 
bands radiate from the centre, are very thick and prominent, 
and have caused great deformity. 

The most common laryngeal tumors are polypoid, which 
are found near and upon the cords, are often lobulated, and 
possess a varying degree of consistency. Cancer also occurs 
in this situation, and is as characteristic here as elsewhere. 
The external wall of the trachea is sometimes the seat of 
cystic tumors of the size of a pea or cherry, having small 
pedicles ; these are dilated mucous glands, as is shown by 
the fact that they communicate with the interior of the tube 
by an opening which is sometimes large enough to admit 
the passage of a good sized probe. Small multiple ecchon- 
droses of the tracheal cartilages are occasionally met with. 

(5.) The Submaxillary Glands. 
The submaxillary and sublingual glands are to be laid 
open by longitudinal incisions, though they are but seldom 
the seat of important pathological conditions. Tumors, both 
syphilitic and other forms, often take their origin here, but 
the only other change which occurs with any frequency is in- 
terstitial suppurative inflammation {adenitis apostematosd) 
12 



178 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

of metastatic nature, in connection with such acute infective 
diseases as typhoid fever, septicaemia, etc. One or both 
glands may be affected. They are enlarged, and in recent 
cases the individual lobules are separated by broad gray 
lines, in more advanced cases by yellow lines of pus. As 
the glandular tissue is usually much reddened, the appear- 
ance of the whole is very characteristic. If the process ad- 
vance still further, collections of pus may be formed both 
in and about the glands (periadenitis apostematosa), which 
may finally be more or less extensively destroyed. In very 
severe cases of phlegmonous sore throat or diphtheritis of 
the fauces the submaxillary glands sometimes become in- 
volved in the process. 

(6.) The Thyroid Gland. 

The lobes are to be laid open by longitudinal incisions. 
The chief pathological conditions assume the general form of 
enlargement, which may be general, or confined to either lat- 
eral lobe, or to the middle or pyramidal lobe: the terms 
bronchocele or goitre include all, and even cancer and sarcoma 
have in this situation been called carcinomatous and sarcoma- 
tous bronchocele, Bronchocele in the more restricted sense, 
however, comprises enlargements originating in either the 
glandular or interstitial tissue, or in the vessels. The first 
of these three varieties is called parenchymatous or hyper- 
plastic, though in accordance with the more modern nomen- 
clature it should perhaps be classed among the adenomata, 
and consists in simple hyperplasia of the glandular alveoli. 
Its cut surface appears granular and of a uniform brownish- 
red color. The most common form is called gelatinous or col- 
loid, and is characterized by a dilatation and distention of the 
alveoli with a translucent yellowish or brownish substance, 
the collections of which project slightly above the level of 
the cut surface, and are larger in proportion as the process 
is the more advanced. The entire gland may be affected, or 
only limited portions, which are usually surrounded by cap- 
sules of fibrous tissue. 



TEE ORGANS IN THE NECK. 179 

This is closely allied with the cystic form, also originating 
in the glandular alveoli, which are rilled with a soft or even 
fluid substance, and are greatly dilated. These cysts may be 
the. seat of hemorrhage, which imparts a brownish-red color 
to their contents — hemorrhagic bronchocele. 

The variety of bronchocele which is characterized as 
fibrous or osseous originates and runs its course chiefly in 
the interstitial tissue, which becomes greatly increased in 
amount, and dense, gradually replacing the glandular ele- 
ments more and more, and finally may become calcified. 
Any or all of the above-mentioned forms are often found in 
combination, and, in fact, scarcely any two bronchoceles are 
exactly alike. 

We now come to the third variety, comprising those forms 
which originate in the vessels. These may be further sub- 
divided into aneurismal and varicose bronchoceles, according 
as the dilatation is arterial or venous. The latter form is 
very apt to be combined with some one or more of the pre- 
ceding forms. Amyloid bronchocele is the result of amyloid 
degeneration of the arteries, and may also occur in the form 
of encapsulated nodules. 

Small tumors not exceeding a cherry in size, and identical 
in structure with true bronchoceles — supplementary bron- 
choceles, so called — are sometimes found, and are consid- 
ered by Virchow to proceed from portions of the gland which 
became detached during foetal life. Since, however, Cohn- 
heim's recent observation of the possible occurrence of a me- 
tastasis from bronchocele, the question must be raised whether 
these forms are not lymphatic glands which have become 
secondarily diseased. Tubercles are sometimes found in the 
thyroid as in most other glands, and purulent interstitial in- 
flammation, such as was described in connection with the sal- 
ivary glands, is found here in rare cases. 

(7.) The Cervical Lymphatic Glands. 
The pathological conditions of the cervical lymphatic 
glands are essentially the same as those of the bronchial and 



180 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

mediastinal glands, and hence need not be described in this 
place. We will merely state that the left supraclavicular 
glands are sometimes secondarily affected in cancer of the 
stomach. 

11. THE DEEP MUSCLES OF THE NECK AND THE CERVICAL 
VERTEBRAE. 

The most important changes which are found here are 
those which are due to caries of the vertebral column. The 
initial stages of this affection are often very difficult of rec- 
ognition, but when fully developed it may lead to retropha- 
ryngeal abscess seated on the anterior surface of the bodies of 
the vertebrae, and extending a variable distance downward, 
sometimes into the muscles. 

12. THE HYDROSTATIC TEST. 

As it is at times of interest, apart from medico-legal 
cases, to determine whether a new-born child has breathed or 
not during or after birth, we will describe the modifications of 
procedure which are enjoined by the Regulations (§ 24) 
as necessary to ascertain this fact. 

The examination is to be begun with the thoracic and ab- 
dominal cavities, not with the head ; and after inspection of 
the abdominal cavity (particular attention being directed to 
the height of the diaphragm) a ligature is to be passed 
round the trachea just above the sternum and drawn tight. 
The sternum and costal cartilages are then to be removed in 
the usual way, the external condition of the thoracic organs 
noted, and the heart examined before its removal. The lar- 
ynx and that portion of the trachea which is above the 
ligature are next to be laid open longitudinally, and the at- 
tention directed to the character of their contents and the 
condition of their walls. " The trachea is then to be divided 
above the ligature and its lower portion removed from the 
body, together with all the thoracic organs. The thymus 
gland and heart are next to be dissected off with care — the 
interior of the latter may now be examined — and the lung 



THE ABDOMINAL ORGANS. 181 

is then to be placed in a spacious vessel filled with fresh cold 
water to see whether it will float. The lower portion of the 
trachea and the primary bronchi are then to be laid open and 
the character of their contents accurately noted. Incisions 
are to be made in both lungs and it is to be noted whether 
the lungs crepitate ; the quantity and character of the blood 
which is squeezed out over the cut surface on gentle pressure 
are likewise to be recorded. Incisions are also to be made 
in the lungs when held under water, in order to see whether 
any air bubbles escape from them ; they are further to be 
separated into their individual lobes, these again into smaller 
portions, and all the pieces thrown into water to see whether 
they will float. The oesophagus is next to be opened, and 
its contents noted. Finally, in case it is suspected that the 
lungs contain foreign or pathological material (vernix case- 
osa, meconium, or an exudation), and are thus rendered im- 
permeable to air, they must be examined microscopically." 

(B.) THE ABDOMINAL CAVITY. 

The usual order in which the abdominal organs are re- 
moved is deduced from the rule already laid down, that no 
organ should be removed, the absence of which would mate- 
rially interfere with the subsequent examination of other or- 
gans. After examining the peritoneum of the anterior ab- 
dominal wall, the organs are to be removed and examined in 
succession as follows: (1) omentum, (2) spleen, (3) left 
kidney and suprarenal capsule, then the same organs on the 
right side, (4) urinary bladder, (5) organs of generation (in 
the male, prostate gland and vesiculas seminales, testes, penis 
and urethra ; in the female, vagina, uterus, the pelvic fibrous 
tissue, Fallopian tubes and ovaries), (6) rectum, (7) duo- 
denum and stomach, (8) the common bile-duct, and the 
portal vein between the layers of the gastro-hepatic omen- 
tum, (9) gall-bladder and liver, (10) pancreas, (11) mesen- 
tery, (12) small and large intestine, (IB) the great blood- 
vessels on the anterior surface of the vertebral column, and 
the retroperitoneal lymphatic glands. 



182 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

It is evident that it will often be found necessary and de- 
sirable to modify this order of procedure ; the operator must 
decide as to the best method to be pursued in any particular 
case, and always choose the lesser of two evils. In many 
cases of chronic peritonitis with extensive adhesions, and 
when the intestines are glued together by a cancerous forma- 
tion, it may be desirable to remove all the abdominal viscera, 
in one mass, in order to be able to examine their mutual 
relations from behind as well as from in front. The intes- 
tines, when much distended with gas or fluid, will often be 
found to be in the way, and to add greatly to the difficulty 
of ascertaining the precise relations of the pelvic organs, 
kidneys, ureters, retroperitoneal lymphatic glands, etc. It 
will be found advantageous, therefore, in these cases, to sep- 
arate the intestine from its mesentery, and remove it from 
the body at the very commencement of the section of the 
abdominal cavity, although it is better to postpone opening 
it till later. 

1. THE PERITONEUM OF THE ANTERIOR ABDOMINAL 

WALL. 

This portion of the peritoneum is often the seat of changes 
of an inflammatory nature. These, when acute, are mani- 
fested by marked redness and injection of the blood-vessels, 
often followed by haemorrhage, and a more or less abundant 
deposit of fibrino-purulent material (fibrino-purulent perito- 
nitis) ; when chronic, by either simple thickening of the 
membrane or more commonly by adhesion between the pari- 
etal and visceral layers (chronic adhesive peritonitis). Ad- 
hesions, as well as other results of inflammation, may be either 
general or local. Both the peritoneum and the adhesions are 
often darkly pigmented from old haemorrhage, and this pig- 
mentation may also occur in the non-adhesive form of in- 
flammation. 

A peculiar form of inflammation, which was long thought 
to be confined to the recto-vaginal and recto-vesical pouches, 
has recently been occasionally observed in the peritoneum 



THE OMENTUM. 183 

of the anterior abdominal wall. This form is completely 
analogous to what has already been described as chronic 
internal hsemorrhagic pachymeningitis, and hence may be 
termed chronic hemorrhagic peritonitis ; it may be accompa- 
nied with profuse hemorrhage into the newly formed false 
membranes — hematoma of the peritoneum. 

Portions of the membrane enclosed by local adhesions may 
be the seat of a suppurative or gangrenous inflammation, 
and the resulting ulceration may deeply implicate the sub- 
peritoneal tissue (ulcerative peritonitis'), and even give rise 
to perforation, the most common seat of which is in the vi- 
cinity of the pelvis, though it also occurs over the gall-blad- 
der and intestine. 

Tuberculosis of the peritoneum is a common affection, and 
may occur in the form of disseminated miliary tubercles 
alone, or, as is more usual, inflammatory products may also 
be present. Such a tubercular inflammation, when acute (as 
has already been mentioned in connection with Abnormal 
Contents of the Abdominal Cavity), is usually associated 
with haemorrhage ; when chronic, with adhesions in which 
the tubercles are deposited in great numbers. 

Cancer in like manner is met with in both the dissemi- 
nated and the inflammatory forms. Lipomata sometimes start 
from the subperitoneal fatty tissue, and may attain consid- 
erable size, projecting into the abdominal cavity. 

2. THE OMENTUM. 

The position and color (the amount of blood which it con- 
tains) of the omentum having been already referred to in 
another place, it merely remains to describe the special mor- 
bid conditions of the part. The normal omentum contains 
a large quantity of fat, especially along the course of the 
blood-vessels, on either side of which it is collected in masses 
like minute bunches of grapes ; in all cases of general wast- 
ing of the body this fat disappears to a greater or less ex- 
tent. Atrophy is, however, not confined to the fat, but may 
affect also the fibrous tissue, which becomes sometimes ex- 



184 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

treniely delicate and may disappear entirely, leaving holes 
of larger or smaller size. Thickening of the fibrous portion 
of the omentum is the result of chronic inflammatory pro- 
cesses (omentitis chronica fibrosa), which may be only local 
and lead to local cicatricial contractions (omentitis fibrosa 
retr aliens')^ or band-like adhesions (omentitis adhozsiva) in 
and between the omentum itself and its adjoining parts. 
Such adhesions occasionally form sacs, into which coils of 
intestine may find their way and become incarcerated. If 
the inflammatory process be widely extended, and if no ad- 
hesions have been formed with other parts, the whole omen- 
tum may shrivel into a thick, dense, grayish white, fibrous 
band lying in front of the colon. When the seat of sup- 
purative inflammation it is greatly reddened, opaque, and 
covered with a fibrino-purulent deposit ; it also shares ac- 
tively in tubercular and cancerous inflammation of the peri- 
toneum, and in these latter affections is very often greatly 
retracted. On cutting into the mass, it is not uncommon 
to find that most of the tubercular or cancerous nodules are 
superficial, while the interior consists chiefly of the normal 
fat. These as well as other new formations are also met 
with in the omentum without inflammation ; in general mil- 
iary tuberculosis, indeed, this is a favorite seat of the tuber- 
cles. It is not always an easy matter to distinguish between 
the larger tubercular nodules and the smaller aggregations 
of fat, especially when the latter are somewhat atrophied, 
and, instead of being yellow, have become rather grayish in 
color. The localization of the bodies in question sometimes 
throws light on their nature, collections of fat always follow- 
ing the course of the vessels, while tubercles are often iso- 
lated in the midst of the fibrous net- work. Tubercles, more- 
over, are always round and usually distinctly spherical, while 
collections of fat are generally oval and somewhat flattened ; 
the smallest tubercles, again, though translucent, are never 
so translucent as collections of fat. If the tubercles are of 
the true miliary type there can be no doubt whatever as to 
their nature. 



THE OMENTUM. 185 

Small Upomata, and single or multiple echinococcus cysts, 
are occasionally met with in the omentum. 

There are few structures the pathological changes in which 
are so easily examined microscopically as in the omentum ; 
it is only necessary to cut out a small bit from a portion 
containing the least amount of the fat and spread it out in 
water, — or in glycerine, or a solution of potassic acetate, in 
case it has been thought best to stain the specimen with 
haematoxyline, aniline, etc. In the foetus which has become 
decomposed in the uterus as well as in the icteric new-born 
child, the presence of yellowish-brown rhombic and needle- 
shaped crystals, both within and without the vessels, is thus 
easily demonstrated, as is also the inflammatory infiltration 
with granulation cells, taking place especially along the course 
of the vessels, and which possess a marked affinity for stain- 
ing fluids. Beautiful specimens may, in like manner, be ob- 
tained of the individual nodules in the disseminated forms of 
tuberculosis, carcinoma, or other new formations. 

If the rules which have been laid down in another place 
are strictly followed, no great difficulty should be encountered 
in determining the nature of a new formation ; it should be 
remarked, however, that tubercles in this situation do not 
invariably contain giant-cells, and that they are, as a rule, 
not so distinctly reticulated here as elsewhere, their ground- 
work being formed of the fibres of the omental tissue itself, 
which are forced apart by collections of tolerably large cells. 
When, in describing the gross appearances, it was asserted 
that tubercles in the omentum are found at a distance from 
the vessels, the remark was not meant to imply that they are 
never found along the course of the vessels also ; on the con- 
trary, the microscope shows active proliferation of the fat 
cells with loss of their fatty contents, and the substitution 
of tubercles in many places for the normal collections of 
fat. 

The study of tubercular as well as of purely inflammatory 
affections of the omentum affords an excellent opportunity 
for verifying another fact which has an important bearing on 



186 DIAGNOSIS IN PATHOLOGICAL ANATOMY; 

general histology; namely, that the endothelial cells, with 
which the whole fibrous framework of the omentum is in- 
vested, increase in size, while their protoplasm becomes 
granular and their nuclei are multiplied, thus forming large 
multinucleated giant-cells. That these may develop into 
tubercles, appears to me questionable, or, at all events, to re- 
quire further proof than has yet been given. I have never 
been able to satisfy myself that pus corpuscles are devel- 
oped from proliferating endothelial cells in inflammatory 
processes ; the great numbers of fat-drops which are always 
found in these cases suggest rather that the endothelial cells 
undergo fatty degeneration and disappear. 

3. THE SPLEEN. 

After freeing the omentum from its attachment to the 
transverse colon, the next step is to remove the spleen, which 
lies behind the fundus of the stomach, and is attached to it 
by delicate areolar tissue. The organ is to be firmly grasped 
in the left hand and drawn far enough forwards to admit of 
severing its vessels near the hilus, attention being directed 
meanwhile to the amount of blood which they contain or 
the presence in them of any pathological change, such as cal- 
cification, aneurismal dilatation, etc. If, as is very often the 
case, the spleen is firmly adherent to the diaphragm, care 
must be exercised in breaking up the adhesions lest the cap- 
sule be torn off and left behind. The gastro-splenic omen- 
tum sometimes contains one or more rounded bodies, from 
the size of a pea up to that of a cherry — accessory spleens — 
which generally present the same pathological changes as the 
main organ. 

(a.) External Examination. 

1. General Appearance. 

(a.) The position of the spleen may be modified by tu- 
mors in its neighborhood, and in rare instances the organ lies 
primarily much lower than normal — the movable or wan- 
dering spleen : the splenic vessels in these cases are in every 



THE SPLEEN. 187 

way normal, except that — in common with the fibrous at- 
tachments of the organ — they are much lengthened, and oc- 
casionally are twisted on their axes, obliterated, etc. The 
possibility of the escape of the spleen into the left pleural 
cavity through a diaphragmatic hernia has been already al- 
luded to. 

(5.) It is often of great importance to determine the 
size of the organ with accuracy. In the adult its average 
weight is 250 grams, its length, eleven to thirteen centi- 
meters, its breadth, eight to nine cm., its thickness, four to 
five cm. 

The following method should be followed when it is de- 
sired to ascertain the exact dimensions of the spleen as well 
as of other organs. Laying the organ on a wooden table or 
board, it should be firmly fastened down by passing a scalpel 
through it vertically, after which the transverse and longi- 
tudinal diameters can be easily measured. The thickness 
may be ascertained by passing the scalpel vertically through 
the thickest portion of the organ, marking the part of the 
knife to which it penetrates with the finger, withdrawing 
the knife, and determining the distance by a measure. The 
spleen may be either increased or diminished in size, the 
former being relatively more common. Diminution in size 
is usually the result of atrophy of the pulp, in consequence 
of which a small spleen is very apt to be at the same time 
dense and hard, and to have a thickened capsule. It occurs 
in old people and those who have been the subjects of gen- 
eral atrophy. The spleen maj^ be enlarged to two, three, 
four, or more times its normal size. Acute enlargement oc- 
curs in all the acute infective diseases (typhoid and typhus 
fevers, relapsing fever, pyaemia, etc.), the organ being soft 
and swollen, with a thin and tense capsule, while the en- 
largement which occurs in intermittent fever (ague-cake), 
leucaemia, and pseudoleucaemia is chronic, and is associated 
with induration of the organ. In amyloid degeneration the 
enlargement is considerable, and the consistency resembles 
that of dough ; in passive congestion, dependent on disease of 



188 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the liver, lungs, or heart, the enlargement is only moderate 
and the tissue is usually dense. New formations of various 
kinds and echinococei are occasional causes of enlargement. 

(<?.) The modifications in form which may be undergone 
by the spleen are manifold, but most of these are of no great 
importance. Congenital fissures of varying depth are some- 
times found on the anterior border, but the chief causes of 
deformity are circumscribed lesions, such as infarctions, tu- 
mors, or echinococei, which generally produce local elevation 
of the surface. Local depressions, and constrictions divid- 
ing the organ into lobes, are sometimes met with as results 
of cicatricial formation which, in its turn, may be the result 
of infarction, syphilis, or injury. 

(c?.) The color of the surface is largely dependent on the 
thickness of the capsule, which transmits the color of the 
parenchyma in an inverse ratio with its thickness. If the 
capsule be thin some idea may be gained of the amount of 
blood contained in the organ, the color being due in a great 
measure to this. The coloration of the surface as a whole is 
less important than that of circumscribed lesions, the nature 
of which can often be determined from their color alone. 
Hemorrhagic infarctions, for instance, when recent are al- 
most black, but with the lapse of time grow more and more 
yellow at the centre, and become surrounded by a narrow 
zone of deeply congested tissue. 

(e.) The consistency of the spleen varies within wide lim- 
its — from that of a mere pulp to that of a dense fibrous struc- 
ture — and depends on the condition of the capsule as well 
as on the composition of the parenchyma. If the former be 
tense, as in acute enlargement, the organ is firmer than if it 
be relaxed, as is the case when an enlarged spleen is return- 
ing to its normal size. The thickness of the capsule may 
also have much to do with the consistency of the organ. 
The condition of the parenchyma, on the other hand, is not 
without its effect in this regard, a spleen which is the sub- 
ject of chronic enlargement being as a rule firmer than one 
which is acutely swollen. 



THE SPLEEN. 189 

2. The Capsule. 

The normal capsule is smooth, thin, and transparent ; but 
it is very liable to thickening, which may be either general 
or local. There is a form of thickening (perisplenitis chron- 
ica fibrosa*) which is generally confined to a portion of the 
surface, and in its higher degrees — amounting to several 
millimeters — results in the formation of whitish homogene- 
ous masses as hard as cartilage, which may further be largely 
calcified. Such thickening, in its lower degrees, is extremely 
common, and appears in the form of nodules or as a network. 
These nodules are so irregularly shaped and, however small 
they may be, of so opaque a gray color, that they are easily 
distinguished from tubercles, which are met with here as on 
all other serous surfaces. In the place of nodules small papil- 
lary growths are occasionally found, often merely the re- 
mains of pre existent adhesions which have been ruptured. 
Adhesions of greater or less extent are very common (pe- 
risplenitis chronica adhoesiva), particularly to the dia- 
phragm, and may be either very close and firm, or long and 
lax. Suppurative inflammation (perisplenitis purulenta) 
occurs here as elsewhere in the peritoneum. The changes 
which are met with in the capsule over the seat of circum- 
scribed affections of the spleen, have already been described ; 
rupture sometimes follows the softening and necrosis which 
occasionally takes place over the seat of softened infarctions 
or abscesses, but may also occur independently of changes 
in the capsule, as after injury, and rarely after marked acute 
enlargement. 

(5.) Internal Examination. 

The parenchyma is to be exposed by a longitudinal incision 
extending completely to the hilus, and by such subsequent 
smaller incisions as the circumstances of the case may re- 
quire. 

1. General Conditions. The most important of these is 
the amount of blood contained in the organ, — a point which 
must always be noted in medico-legal cases. It is indicated 



190 DIA GNOSIS IN PATHOLOGICAL ANATOMY. 

by the freedom with which the blood flows from the cut 
surface of the larger vessels, and by the color of the par- 
enchyma, which, in the spleen more than in any other organ, 
by reason of its peculiar anatomical structure, is dependent 
on the amount of blood. The color of the normal spleen 
is dark red, darker and more inclining to purple in children 
than in adults, but it varies pathologically from a light red- 
dish-gray or reddish-brown to a reddish-black. 

There are also certain other coloring matters which may 
modify the appearance of the organ : hsernatoidine imparts a 
brownish shade, the coloring matter of the bile a yellowish 
tint, and in intermittent fever the spleen is deeply pigmented 
with a black material which is derived in some way from the 
blood. There are finally some pathological processes, which 
render the organ almost uniformly gray, among which the 
hyperplasia of the fibrous framework which is met with in 
chronic enlargement (intermittent fever, leucaemia) is the 
most worthy of mention. 

In studying pathological changes in the parenchyma its 
three chief component structures must be borne in mind — 
pulp, follicles, and trabeculae — for the reason that they may 
be affected independently of one another ; all three may be 
the seat of hypertrophy, either singly or conjointly. The 
follicles vary in size, from that of a poppy-seed to that of 
a pin's-head; the traheculce appear as delicate gray lines, 
as a rule, but are rather coarser at their junctions with the 
capsule or the larger vessels. General hyperplasia of the 
fibrous framework is most marked when due to passive con- 
gestion ; local hyperplasia of the superficial portions of the 
organ is rather the result of a chronic perisplenitis. The 
follicles vary considerably both in size and number, and often 
participate in the enlargement of other lymphoid structures 
in the body. When the pulp is the seat of acute enlarge- 
ment, it projects from the cut surface, rendering it somewhat 
uneven, and hides the follicles and trabeculae more or less 
from view. Careful examination shows that the irregularity 
of the cut surface is due to isolated prominences, the size of 



THE SPLEEN. 191 

a split pea, each one of which represents an arterial twig, 
and the tissue supplied by it. The pulp is without question 
the most important of the three constituents of the organ, 
since its hyperplasia plays the chief part in the formation 
of most of the so-called splenic tumors. Even acute swel- 
ling, though due in considerable measure to accumulation 
of blood in the organ, depends essentially on genuine hyper- 
plasia, or cellular growth, as may readily be seen in fresh 
needle preparations ; the large splenic cells with single 
clearly defined nuclei are those which especially show signs 
of an active growth, many of them becoming multinucle- 
ated, especially in the spleen of typhoid fever. In this dis- 
ease, as well as in others which are associated with acute 
swelling of the spleen, the organ contains great numbers of 
cells with red blood disks imbedded in them ; these cells 
are also found in the normal spleen, particularly of young 
people, but in vastly fewer numbers. In relapsing fever, es- 
pecially, the blood of the splenic vein contains many granular 
corpuscles, and fatty degenerated endothelial cells derived 
from the walls of the smaller veins. In the hyperplastic 
spleens of infective parasitic diseases — and above all, in 
malignant pustule, — the parasites are found in abundance 
in the tissue. 

In chronic hyperplasia of the pulp we find in the place of 
round cells a formation of fibrous tissue which encroaches 
on and destroys the pulp itself ; but in these cases it is im- 
possible to draw a close distinction between hyperplasia and 
inflammation. In chronic enlargement we find almost inva- 
riably numbers of cells containing granules of pigment. 

Atrophy also may involve any or all of the structures 
which enter into the composition of the organ, but is most 
common and most marked in the pulp. It often happens 
that the trabecular are thus rendered more prominent than 
they are in the normal condition, and one might easily be led 
to consider them the seat of hyperplasia, as indeed they 
sometimes are in atrophy of the pulp and follicles. Atrophy 
of the pulp is indicated by a brownish-red or rust-colored 



192 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

appearance, and the presence of cells containing granules of 
brownish -red pigment. 

2. Special Morbid Conditions. 

(a.) One of the most common and characteristic of these 
is amyloid degeneration, which occurs in two separate forms, 
easily distinguishable by the naked eye, though both cause 
more or less enlargement of the organ, and a change in its 
consistency. In both the organ is firm, and so inelastic as 
to pit very markedly on pressure, but this change is more 
pronounced in the second of the two forms which we are 
now about to describe. The first form, and the easier 
of recognition, is amyloid degeneration of the follicles, a de- 
generation which starts in the arteries, but subsequently in- 
vades the whole structure of the corpuscles, which are en- 
larged beyond the size of a millet-grain, and project above 
the level of the cut surface as glossy, translucent nodules, 
bearing a close resemblance to boiled sago — hence the term 
sago-spleen. The centre of each of these nodules sometimes 
appears as a small gray point, corresponding with the 
position of the arterial twig to which the follicle is attached, 
and the enlarged follicle is not uncommonly surrounded by a 
narrow red zone of collateral hyperemia. Amyloid change 
occurs not only in follicles surrounded by otherwise normal 
splenic tissue but also in those imbedded in diseased tissue — 
in hemorrhagic infarction, for instance. 

The reaction with iodine presented by a tissue which has 
undergone amyloid degeneration is very peculiar and charac- 
teristic. All albuminous substances, when brought in contact 
with this reagent, become of a yellow color, which is more 
or less deep according to the intensity of the reaction; but 
the tissues which have undergone amyloid degeneration be- 
come dark mahogany-red, at times almost brown, and are 
thus clearly brought into view, especially when acetic acid 
has been poured over the cut surface to render it more trans- 
parent. If the amyloid change be very slight the microscope 
should be used, and it will generally be found that fresh 
sections with the double knife answer every purpose. Iodine 



THE SPLEEN. 193 

stains the amyloid portions wine-red, the others light yel- 
low. Methylaniline hydriodide is a reagent which may be 
used with great advantage, a weak solution staining the nor- 
mal cells and nuclei blue and the amyloid masses light red ; 
the colors remain permanently in specimens put up in glyce- 
rine and potassic acetate, while the effect of iodine is very 
evanescent. 

The second form is very difficult of recognition in its early 
stages, and does not always respond to reagents with suffi- 
cient distinctness to spare us the use of the microscope. In 
this form the amyloid change attacks the vessels of the pulp, 
and in well-marked cases renders the spleen smooth, some- 
what glistening, firm, inelastic, reddish-gray in color, and 
somewhat translucent. Such a spleen is called lardaeeous or 
waxy (Speckmilz, Rokitansky ; Schinkenmilz, Virchow). 

The reaction with iodine alone is often very feebly marked 
in the early stages of the process, and great practice is then 
required to recognize the change even when this reagent is 
supplemented by sulphuric acid, which changes the dark-red 
color produced by iodine in the diseased portions to a blue ; 
sometimes, indeed, however practiced the eye may be, the 
use of the microscope is indispensable. This form of amyloid 
degeneration renders the tissue so firm and dense that sec- 
tions are made with relative ease, and by staining the sections 
with methylaniline the extent of the process is clearly shown, 
as well as its predominance in the walls of the vessels of the 
pulp. 

(6.) Acute inflammation terminating in suppuration is not 
common in the spleen, but does occur both as a result of in- 
flammation near the organ and as a primary condition in re- 
lapsing fever, embolism, etc. The great increase in size and 
firmness, and the more or less dark-brownish or slaty look 
which occur in intermittent fever, are really due mainly to 
chronic inflammation. The septa are thickened, and appear 
as distinct gray lines running in every direction, and the 
dark color of the cut surface is due to pigment contained in 
the splenic cells which can easily be isolated by means of 

13 



194 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

needles. This pigmentary change must not be confounded 
with the small black spots found scattered throughout the 
spleen of aged people ; in this latter case the pigment is de- 
posited only in the walls of the larger vessels and in their 
vicinity, but not in the pulp itself ; both forms of pigment 
are derived in some way from the blood. 

The spleen of leucaemia, characterized by its density and 
reddish-gray color, is also to be regarded as the result of a 
chronic inflammatory process. In the earliest stage of leu- 
caemia the process consists solely in cellular hyperplasia of 
the pulp in consequence of some irritation (inflammation), 
and the organ is soft and of a dark-red color ; the next step 
is the conversion of the tissue of the pulp into fibrous tissue, 
a process to be regarded as inflammatory. In very many, 
though not in all, cases, the hyperplasia involves the follicles 
also, rendering them as large as a hemp-seed, pea, or even 
larger ; they acquire an elongated-oval shape, though they 
are sometimes more pointed at one end than the other, and 
have an opaque, whitish shade. In cases of long standing, 
granules of brownish pigment are often deposited in the cells 
of the pulp. Leucaamic spleens invariably contain large num- 
bers of colorless octahedral crystals, the chemical composition 
of which has not as yet been ascertained. The blood of the 
splenic vein contains vast numbers of white blood corpuscles, 
many of which resemble in every respect the cells of the 
pulp of the spleen. 

Metastatic inflammation and abscesses occupy a special 
position in the spleen as in the lungs, and though closely 
allied to hemorrhagic infarction, differ from this condition 
since the embolus which acts as the cause has a septic char- 
acter. Embolic abscesses, as was observed in connection 
with the lungs, are usually small, and often surrounded by 
a zone of inflamed tissue ; the pus is of a dirty reddish-yel- 
low color, from admixture with the spleen substance. Mi- 
crococci in enormous numbers are easily demonstrated in the 
softened portions. 

(0.) Hemorrhagic infarctions vary greatly in size, some- 



THE SPLEEN. 195 

times being of tbe size of a pea, though usually larger than 
that, sometimes involving half the organ. They project 
above the level of the surrounding surface, are wedge-shaped, 
with the apex toward the hilus, firm, and, according to their 
age, of a dark-red, yellowish-red, or simple yellowish-white 
color. The yellow forms are always of relatively long stand- 
ing, and were formerly called fibrinous deposits, their real 
nature not having been made out ; in some rare cases, the 
follicles within their limits are found to have undergone most 
marked amyloid degeneration, a proof that the actual splenic 
structure is the seat of the change. Infarctions are almost 
always surrounded by a dark-red zone of haemorrhage, which 
but rarely passes over into one of inflammation ; as in other 
organs, the early stages present on microscopic examination 
a fatty degeneration of the cellular elements, and a subse- 
quent conversion of the latter into minute granules of fatty de- 
tritus. It sometimes happens that the infarctions are ab- 
sorbed and narrow fibrous cicatrices are left, which may 
contain small deposits of lime salts, and betray their mode of 
origin by an orange-yellow pigmentation due to hsematoidine. 
Infarctions may also undergo softening, and a cavity with 
soft, brownish contents result. 

(c?.) Syphilitic affections of the spleen are rare, whether 
in the form of gummata or in that of circumscribed inter- 
stitial inflammation ; tubercular changes, on the other hand, 
are very common. Primary tuberculosis of the spleen must 
be very rare, if, indeed, it ever occurs ; but nowhere is sec- 
ondary tuberculosis more common than in this organ. There 
are two forms in which the affection may appear : in the first 
and most frequent, the tubercles are disseminated and very 
small ; the largest do not surpass a millet-grain in size, and 
these alone present a central opacity and a yellowish tinge, 
evidences of commencing caseation. The great majority of 
the tubercles are very minute, but may be thousands in num- 
ber, and are gray and translucent. When only moderate 
numbers are present, they are not always easily to be dis- 
tinguished from the Malpighian follicles. Tubercles have a 



196 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

somewhat foreign appearance, as if they did not belong in 
the tissue ; they project above the level of the cut surface as 
little spheres, and can be removed entire from their attach- 
ments, while the follicles do not project at all, and, when it 
is attempted to pick them out, they break down, liquefy as it 
were — the reason why they were formerly called "vesicles." 
The microscope further shows that the follicles invariably 
contain a small artery, which tubercles never do. 

The second form of tuberculosis is chiefly met with in 
young subjects (scrofulous children), and is characterized 
by the large size of the tubercular nodules, which are often 
manifestly conglomerate and always more or less cheesy. 
They appear as discrete yellow masses when seen through 
the capsule, of the size of a hemp- seed or pea, or even larger, 
and are evidently composed of an aggregation of smaller 
nodules ; on laying the organ open they are found scattered 
through the tissue, but never in such great numbers as is the 
case with the first variety. These nodules, as is seen with 
special distinctness when they lie under the capsule, are sur- 
rounded by narrow bright-red zones, composed of hypersemic 
blood vessels (collateral hyperemia). 

(e.) In the rare cases of malignant lymphosarcoma, so 
called — particularly when it originates in the cervical lym- 
phatic glands — the spleen is the seat of a new formation of 
a peculiar character. The follicles are universally enlarged 
to a varying degree, sometimes to the size of a cherry or a 
walnut, and the spleen may then greatly resemble that va- 
riety of leucasmic spleen in which the follicles, as well as the 
pulp, are hyperplastic ; it is to be distinguished from the latter, 
however, by the absence of any increase in the colorless 
blood corpuscles, — hence Cohnheim's term, pseudoleucaeniia. 
The enlarged follicles vary somewhat in consistency, the 
firmer ones being composed of spindle-cells and fibrous tis- 
sue ; the larger ones are sometimes yellow at the centre 
from fatty degeneration. Other tumors — carcinoma, sar- 
coma, etc, — are rare and almost exclusively secondary. 

(f.) Ecchinococci are sometimes single, sometimes multi- 



THE KIDNEYS AND SUPRA-RENAL CAPSULES. 197 

pie ; the former are sometimes so large as to occupy nearly 
the whole spleen. 

(#.) Of the affections of the splenic vessels we have 
already mentioned aneurism and embolism ; in cases of in- 
farction the veins are sometimes the seat of secondary throm- 
bosis, and they occasionally contain calcified thrombi, phle- 
bolites, sometimes in large numbers, the origin of which can- 
not be traced. 

4. THE KIDNEYS AND SUPEA-KENAL CAPSULES. 

Each kidney and supra-renal capsule are to be removed 
together, first the left and then the right. After detaching 
the splenic flexure of the colon where its attachments hide 
the left kidney, the fundus of the stomach and the tail of 
the pancreas are to be raised sufficiently to expose the supra- 
renal capsule in its full extent, when this body is to be freed 
with the knife anteriorly and superiorly. A long incision 
then being made over the outer convex border of the kidney, 
this organ is to be separated with the left hand from its in- 
vesting loose cellular tissue, and drawn forcibly upwards, 
being removed from the body with its accompanying supra- 
renal capsule after a simple cut has been made across the 
vessels and ureter. As the right supra-renal capsule is firmly 
attached to the inferior surface of the liver, the latter organ 
must be turned upwards and the former dissected away from 
it, great care being taken to avoid injury to the inferior 
vena cava ; the steps then to be followed are the same as 
those on the left side. In all cases in which such changes 
are suspected in the ureters as might give rise to hydrone- 
phrosis, as well as in all cases in which the disease is still ob- 
scure, the size of the ureters should be carefully inspected 
before the kidneys are separated ; the kidneys, ureters, and 
bladder connected together may then be removed from the 
body, that the seat and nature of the possible obstruction 
may be accurately determined. The whole course of the left 
ureter lies open to inspection without further dissection ; but 
in order to expose the right ureter, the peritoneum must be 



198 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

divided where it is reflected from the posterior abdominal 
wall over the eoecum and ascending colon, the membrane 
being put on the stretch, and injury to the subjacent parts 
at the same time avoided by strong traction on the intestines. 
It is usually necessary to remove only the upper portion of 
the ureter with the kidney. 

The method of procedure which we have thus described 
can, of course, only be followed when there is no malposition 
of the kidneys, and, as should not be forgotten, malposition 
of the kidneys does not necessarily involve malposition of the 
supra-renal bodies also. Malposition may be either acquired 
— that is, the organ is not fixed, but freely movable with 
lengthened vessels, and is thus characterized as floating, 
wandering (ren mobilis, most common on the right side) — 
or congenital ; in the latter case the organ is attached in an 
abnormal position, sometimes at the entrance of the true pel- 
vis, and its vessels are not, as in the former case, given off 
in the regular way, but may be several in number for each 
kidney instead of one. Another congenital condition, always 
involving dislocation downwards, is fusion of the two organs 
into one (ren concretus, coalitio renum). The seat of the 
fusion, which varies considerably in extent, is invariably at 
the lower ends, and, in its most typical form, constitutes 
what is known as the horse-shoe kidney, lying across the 
vertebral column. In this case, also, the origin of the vessels 
deviates from the normal. 

(a.) THE SUPRA-RENAL CAPSULES. 

After noting the external appearances of these organs, 
their size, form, etc., and the condition of the fibrous and 
fatty tissue which surrounds them, they are to be opened in 
their longest diameter through their flattened surface. 

The supra-renal capsules — which are often accompanied 
by similar small accessory bodies — are relatively larger in 
children than in adults, and are flattened and somewhat tri- 
angular in shape : the cortical portion is light-yellow in 
adults, grayish-red in children ; the medullary portion is 



THE KIDNEYS AND SUPRA-RENAL CAPSULES. 199 

gray, and the narrow zone of intervening tissue is brown ; 
the consistency is firm. Since this intermediate zone softens 
very rapidly after death, and is liable to be torn open in re- 
moving the organ, a cavity may be produced; the term be- 
stowed on these bodies by the ancients — capsular atrabili- 
ares — thus arose. The cortical portion loses its fat in all 
wasting diseases and becomes gray instead of yellow. 

In cases of extensive amyloid degeneration the capsules are 
not spared, but become enlarged, very firm, and turn brown 
on the addition of iodine ; this change attacks chiefly the 
cortical portion. Acute inflammation is rare, but is met with 
both in the suppurative and the hgemorrhagic forms ; effusions 
of blood of considerable size are sometimes found. The cap- 
sules, like the thyroid gland, are sometimes the seat of hy- 
perplasia, which may be either nodular and circumscribed, 
or distributed uniformly throughout the glands, a condition 
to which the term struma suprarenalis has been applied by 
Virchow. This increase of the glandular tissue originates 
invariably in the cortex, and hence usually presents the same 
light yellow color and fatty cells as that portion. Small 
cysts are sometimes found. There is another form of lobu- 
lated hyperplasia which originates in the medullary portion, 
and resembles it in its grayish color ; according to Virchow 
this form arises from the fibrous groundwork of the (ner- 
vous?) medullary portion, and he has therefore termed it 
glioma. 

The most interesting affection of the supra-renal bodies is 
cheesy degeneration, usually associated with similar changes 
in other organs, but sometimes limited to one or both of 
these organs ; it may occur in the form of small, isolated, 
cheesy nodules, or involving the whole organ uniformly, may 
often cause a considerable increase in its size. The cheesy 
masses, as a rule, are homogeneous, firm, and dense ; but 
are sometimes soft, friable, and even puriform. Their origin 
is in some cases manifestly tubercular, as isolated tubercles 
are found in their immediate vicinity, though this is not a 
constant appearance : Virchow nevertheless regards cheesy 



200 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

degeneration in these bodies as invariably of genuine tuber- 
cular origin. The connective tissue surrounding the capsules 
which have undergone this change is sometimes the seat of 
chronic inflammatory thickening. 

Grummata are rare, sarcoma is tolerably rare, and cancer 
somewhat more common. The latter is occasionally primary, 
more commonly secondary to cancer of the liver, sexual or- 
gans, stomach, etc., and may be either unilateral or bilateral. 

In connection with a peculiar brown discoloration of the 
skin, we referred to its association with diseases of the supra- 
renal bodies (Addison's disease'), and stated at the same 
time that such association is by no means constant. The 
cutaneous discoloration is least constant in cancerous, most 
common in cheesy, degeneration ; but even the latter condi- 
tion may be present without bronzing of the skin, while 
the skin may be bronzed precisely as in Addison's disease 
without the existence of cheesy degeneration, or of any other 
change in the suprarenal bodies. These facts have induced 
many observers to attribute the cutaneous discoloration rather 
to changes in the neighboring sympathetic nerves — the solar 
plexus and the semilunar ganglia — which, together with the 
connective tissue investing them, should therefore always be 
carefully examined. 

(b.) THE KIDNEYS. 

After inspection of the capsular portions (the fatty, and 
the fibrous, or true, capsule) they are to be divided by a 
superficial incision along the convex margin of the kidney 
and stripped off that organ, the external condition of which 
is then, in its turn, to be noted. The next step is to lay open 
the kidney itself as far as its pelvis by a longitudinal incis- 
ion in the same line as that through the capsule, and then to 
examine the parenchyma, the calices, the pelvis, and the 
ureter. In making this incision the organ should be held 
firmly in the left hand, with the hilus and the reflected layers 
of the capsule in the angle between the thumb and fingers, 
and laid open from end to end as far as the hilus so as to 
expose the largest possible surface. 



THE KIDNEYS 201 

1. The Capsules of the Kidney. 

The fatty tissue of the outer capsule participates in the 
general changes of the fatty tissues of the body as a whole, 
and is peculiarly subject to mucous atrophy (see Heart). 
In corpulent persons it is very thick and may prove a source 
of error in estimating the size of the kidneys, though there 
is still greater danger of this in cases of local hyperplasia of 
this tissue, a condition sometimes found as a sort of compen- 
sation in cases of atrophy of the kidney itself. The fibrous 
capsule is usually thin, translucent, easily detached from the 
surface of the kidney, and is composed of two layers which 
may become separated, the inner remaining attached to the 
kidney. In chronic inflammation of the kidney, this capsule 
becomes thickened and adherent, so much so that in stripping 
it from the kidney small portions of that organ are also torn 
off, and remain attached to it ; similar thickening may also 
be caused by chronic inflammation in the tissue about the 
kidney (chronic fibrous perinephritis'). Purulent inflam- 
mation about the kidney (suppurative perinephritis) may 
originate in that organ itself (rupture of abscesses, etc.), or 
in neighboring organs (psoas-abscess, caries of the vertebrae, 
etc.). 

Accessory kidneys are sometimes found between the two 
layers of the fibrous capsule as well as between that struc- 
ture and the kidney, and are easily recognized as such by 
the three layers of which they are composed. 

2. The Outer Surface of the Kidney. 

(a.) General Conditions. 

1. The ordinary size of the kidneys, assuming the average 
normal weight to be one hundred and fifty grams, is repre- 
sented approximatively by the following figures, but may 
surpass them as well as fall short of them : length, eleven 
centimeters ; breadth, five centimeters ; thickness, three- 
fourths of a centimeter. Enlargement occurs in acute pa- 
renchymatous and interstitial affections, — especially in sup- 



202 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

purative nephritis and in pyelonephritis, — also in connec- 
tion with new formations, to a less degree in passive conges- 
tion, and finally, when the kidney is considered as a whole, 
in hydronephrosis. Very marked compensatory enlargement 
of the kidney takes place when its fellow is atrophied ; such 
enlargement is not, however, strictly speaking, pathological. 

The simplest form of atrophy is that which is unassociated 
with any other special change, and is met with in cases of 
general wasting of the body ; the most important forms are 
those which are the result of inflammation, which is then 
always chronic in character, and involves either the paren- 
chyma or interstitial tissue alone, or, more commonly, both 
together. According to the character of the surface of the 
organ, a distinction is drawn between smooth atrophy, the 
result of interstitial inflammation, and granular atrophy, the 
result of parenchymatous inflammation or of the latter in 
combination with the interstitial form. The prominences 
which are seen on the surface in granular atrophy vary some- 
what in size, but are generally about as large as a pin's head, 
and consist of true renal tissue which has become more or 
less altered in character, while the depressions are the atro- 
phied portions. In this connection it is important to remem- 
ber that the Malpighian corpuscles are never normally 
found in the tissue immediately underlying the capsule, but 
are always separated from it by a layer of convoluted tubes ; 
atrophy must hence be present when these bodies are found 
to be superficial. 

2. The shape of the kidney is modified in cases of enlarge- 
ment, of atrophy (particularly when local), and of all circum- 
scribed lesion, as would naturally be supposed. The normal 
foetal kidney is lobulated, and this condition often persists 
into advanced life, the surface being more or less deeply fis- 
sured and divided into distinct portions. Kidneys which are 
the seat of congenital malposition are very apt to be flattened 
in their transverse diameter (from the hilus to the convex 
border) with the hilus in the midst of the flattened, and, as 
a rule, superior, surface. The horse-shoe kidney has been 
already described. 



THE KIDNEYS. 203 

3. The color of the surface depends on the amount of blood 
contained in the organ, the number of stellulae Verheynii, 
and the condition of the parenchyma — particularly that of 
the epithelium of the convoluted tubes. The normal color is 
grayish-red, but passes over into whitish-gray, and finally yel- 
lowish-gray, as a result of parenchymatous changes. Chronic 
jaundice produces a peculiar yellowish, greenish, or almost 
black, discoloration, or a combination of these shades, result- 
ing in a mottled appearance. Local change of color is caused 
by all circumscribed lesions, haemorrhage, infarction, ab- 
scess, tubercle, and tumors. A portion of the right kidney 
is often found after death to be stained with the bile, and 
decomposition extending from the intestine may impart a 
dirty greenish shade to the surface of the left kidney. 

4. The consistency of the kidney is generally firm and 
elastic ; it is increased in passive congestion, in the various 
forms of atrophy, in chronic interstitial processes, etc. The 
consistency is greatly diminished in parenchymatous inflam- 
mation, whether in the stage of cloudy swelling or in that 
of fatty degeneration, and somewhat so in acute interstitial 
inflammation. 

(b.~) Special Morbid Conditions, 

Some valuable conclusions as to the nature of circum- 
scribed lesions of the kidney may be drawn from the inspec- 
tion of its external surface alone. We have already alluded 
to the fact that the glomeruli become visible here in atrophy, 
and when they assume the form of small white or whitish- 
yellow dots, we are justified in assuming them to be calcified. 
Haemorrhagic nephritis, which may be either parenchyma- 
tous or interstitial, is shown by the presence of minute 
punctiform haemorrhages scattered over the surface. The 
intestinal gases sometimes change the color of these haem- 
orrhages from red to black ; but this can be recognized as a 
post-mortem change by its being usually limited to the 
lower border of the left kidney, which portion is thus apt to 
be the seat of a general slaty discoloration. Old points of 
haemorrhage are also black, or nearly so, in consequence of 



204 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the changes undergone by the blood-pigment ; these are read- 
ily distinguished from those black spots due to decomposition 
which we have just described by their uniform distribution 
over the whole surface of the organ. 

The changes which are brought about by hemorrhagic 
infarction are very characteristic, and resemble closely those 
in the spleen, which are due to the same cause ; the periphe- 
ral zone of hyperemia is generally very clearly denned. 

The arrangement of the renal vessels is such that embolic 
or metastatic abscesses, when present, are apt to be very 
numerous, though of small size, thickly studding the whole 
surface of the organ with yellow nodules which project some- 
what above the surface, varying in size between that of a 
pin's-head and that of a hemp-seed. Each is surrounded by 
a red zone of inflammation, and is often covered by a thin 
layer of injected tissue; sometimes they are collected to- 
gether in groups at one or more places, forming a large red 
spot within which the isolated yellow nodules are still clearly 
defined. Occasionally they are of larger size and cannot be 
mistaken for anything else than what they really are — ab- 
scesses. Every minute abscess in the kidney cannot, how- 
ever, be summarily attributed to embolism, since they may 
be due to non-embolic suppurative interstitial nephritis, such 
for instance as is sometimes associated with purulent or diph- 
theritic inflammation of the efferent urinary apparatus (py- 
elo-nephritis). All doubt is dissipated after the organ has 
been laid open. Gray submiliary or miliaiw tubercular 
nodules are also met with on the surface of the organ, not 
infrequently collected in little groups, and are distinguishable 
from minute abscesses by their greater firmness of structure. 
Large tubercular nodules are but rarely met with in this 
situation. 

All the varieties of tumors to which the kidney is subject 
may, of course, make their appearance on the surface, but 
present no peculiarities here which they do not possess else- 
where ; cysts, however, are so very common here, and so 
peculiar in some respects, as to deserve more than mere pass- 



THE KIDNEYS. 205 

ing notice. Cysts are of the most variable size, some being 
scarcely appreciable, some as large as the fist ; but small 
cysts are much more common and are generally multiple, 
while the largest ones are always single, and being found in 
kidneys which are otherwise healthy, may therefore be looked 
upon as congenital. There is a peculiar variety of congeni- 
tal cystic kidney (hydrops renum cysticus) which is found 
chiefly in new-born children (those which are still-born as 
well as those which die at an early period), but is also ex- 
ceptionally met with in adults, and is always bilateral. The 
kidneys are enormously enlarged, and appear to be com- 
posed almost exclusively of thickly aggregated cysts with 
pale, clear, watery and albuminous contents ; in young sub- 
jects these cysts vary between the size of a pin's head and 
that of a cherry-stone, but are apt to be rather larger in 
adults, sometimes attaining the size of a walnut. 

All other small multiple cysts are acquired, consisting of 
dilated and confluent urinary tubules, and, according to Vir- 
chow, are the results of chronic interstitial inflammation. 
The contents of the smaller cysts are often firm and gelat- 
inous, those of the larger ones are usually a thin and clear 
liquid ; hsemorrhage often takes place into individual cysts, 
the contents of which are then generally reddish or brown- 
ish in color, but are occasionally yellow, rather thick, and 
fatty. All varieties of cysts have a thin wall of fibrous tis- 
sue, which is lined by tessellated epithelium ; the walls of 
congenital cysts are always smooth, while those of the ac- 
quired varieties often present projections and ridges, the re- 
mains of the walls of the tubes. 

3. The Surface of the Section of the Kidney. 

(a.) General Considerations. 

After having laid the kidney open, the first point to be 
noted is the relative proportion of the cortical and medullary 
portions, a point which may throw great light on the nature 
of the pathological process, if such be present. The width 
of the cortex is of especial importance, the average in adults 



206 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

being from five to six millimeters. Increase in the cortex 
points to recent inflammatory processes (chiefly of the par- 
enchyma), while diminution points to chronic inflammation 
and consequent atrophy; a diminution in the height of the 
papillae of the medullary portion or their effacement, on the 
other hand, is a mechanical result of excessive distention of 
the calices (hydronephrosis, etc). It is a noteworthy fact, 
that the inner portions of the cortex, which fill out the 
spaces between the pyramids of the medullary portion, and 
are called septa Bertini, do not always show the same degree 
of change as the rest of the cortex; they may, for instance, be 
unduly swollen in parenchymatous inflammation, or, on the 
other hand, be relatively little diminished in size in atrophy. 

The amount of blood contained in the organ, as a whole, 
and the relative distribution of the blood in the several parts, 
are next to be considered. In many forms of parenchyma- 
tous inflammation, the contrast between the gray or yellow 
opacity of the cortex and the deep congestion of the medul- 
lary portion, is very marked and characteristic. In the cor- 
tex a distinction must be drawn between the amount of 
blood contained in the glomeruli and that contained in the 
other vessels. When the former are full of blood they ap- 
pear as minute red dots ; when empty, they are either not 
visible at all or appear as minute pale dots or specks, espe- 
cially when the light is allowed to fall obliquely on the cut 
surface. The color which belongs to the tissue itself, apart 
from the amount of blood present, is especially noteworthy 
from the light which it throws on the condition of the secre- 
tory portions of the organ. These portions lie chiefly in the 
cortex, and this part should, therefore, be closely examined. 

A distinction must be drawn in the cortex between the 
pyramids of Ferrein and the region of the convoluted tubes ; 
the former are composed solely of bundles of straight tu- 
bules, which are gray, translucent, and somewhat conical in 
shape, with their bases resting on the medullary portion. 
The region of the convoluted tubes is the labyrinth which 
contains the vessels and Malpighian bodies, all the convoluted 



THE KIDNEYS. 207 

tubes and a portion of the looped tubes of Henle. These 
latter portions are of a more whitish gray than the pyramids 
of Ferrein, if the part which the blood plays in their colora- 
tion be disregarded. They also show the most frequent mod- 
ifications of color, since it is in them that parenchymatous 
inflammation first makes its appearance, and often remains 
confined to them alone. Modification of color in these parts 
depends first on an opacity of the tissue, which looks as if it 
had been boiled in water, though the convoluted tubes are 
more clearly to be distinguished than in the normal condition, 
and appear as minute lines and dots ; and, secondly, on the 
presence of a more or less marked and pure yellow color, 
which varies between a very indistinct yellowish-gray and an 
intense lemon- or butter-yellow. 

The pyramids of Ferrein are less subject to changes of 
color, but are sometimes increased in width, and become the 
seat of a grayish opacity, or a yellow discoloration in the 
form of narrow and delicate lines. 

This latter remark applies also to the tubes of the medul- 
lary portion, of which those lying within and in the immedi- 
ate vicinity of the papillae are occasionally found to be the 
seat of marked white, yellow, yellowish-red, or brown discol- 
oration. Jaundice gives rise to a yellowish-green discolora- 
tion which is more widely distributed, but is most marked 
in the medullary pyramids, and, above all, in their papillae. 

Decomposition gives rise to a dirty, dark-red discoloration 
of the whole parenchyma, which discoloration subsequently 
assumes a greenish cast. The tissue is then soft and easily 
crushed, and, if decomposition is well advanced, contains 
numbers of small bubbles of gas which (especially when seen 
from the outside of the organ) have some resemblance to 
small circumscribed points of fatty degeneration. 

(5.) Tlie Separate Affections. 

When the separate affections are described in general, the 
first to be considered is — 

1. Hemorrhage. This may occur as a simple haemorrhage, 
as for instance in the papillae in cases of hemorrhagic small- 



208 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

pox, or as a part of some other affection, as in inflamma- 
tion. In the latter case it is usually more marked on the 
surface than in the deeper portion of the cortex, though not 
altogether absent. Brown or blackish pigment granules are 
found within the convoluted or straight tubules, as a result of 
old haemorrhages. Hoemorrhagic infarction is next to be con- 
sidered. It presents a defined wedge-shape and extends, ac- 
cording to its size, to or into the pyramidal portion. The 
wedges are either red, reddish-yellow, or yellow " fibrinous 
deposits," surrounded by a red areola, and the structure of 
the kidney (especially the glomeruli) may be recognized 
within them. Very minute septic emboli produce miliary 
haemorrhagic infarctions which are usually connected with 
the formation of abscesses. This subject will be again re- 
ferred to in connection with metastatic inflammation. 

2. Among the diseases which proceed from the vessels 
amyloid degeneration is to be mentioned, as it always first 
appears in them and usually in the afferent arteries of the 
glomeruli. This affection may often be diagnosticated with 
the unaided eye and without the help of reagents, by the 
great prominence and the peculiar vitreous appearance of the 
glomeruli upon the cut surface. The diagnosis becomes 
positive if they are turned brown upon the application of 
iodine. In a more advanced stage the other vessels of the 
cortex are affected, also the vasa recta of the pyramids, 
which in some cases are most changed, and finally the degen- 
eration advances to the tunicae propriae of the urinary tubules, 
which, however, can only be recognized by the aid of the 
microscope. Sections may be most conveniently made with 
the double knife, cutting perpendicularly (in the direction of 
the tubules of Ferrein) through the cortex and pyramidal 
portion. They are then to be stained with aniline-blue, 
when the amyloid material will appear red in contrast with 
the healthy tissue, which will be colored blue. The degener- 
ation of the tunicae propriae is most easily recognized by pick- 
ing apart the sections which have been colored with aniline, 
for in so doing there is less liability of confounding the tu- 



THE KIDNEYS. 209 

nicae with the accompanying vessels. In recent cases the 
partially affected glomeruli look very pretty, the intact coils 
presenting a blue and the degenerated portions a red color. 

3. Finally, thrombosis of the renal veins should be men- 
tioned among the affections of the vessels ; this may be ob- 
served to extend from the spermatic veins (especially the 
left), or to occur spontaneously, for instance in the new-born 
(marantic thrombosis) and in adults with tumors of the 
kidneys. In many cases of carcinoma and sarcoma of the 
kidney, a thrombus of the veins is formed by the extension 
of the new formation into them, and in this way the vena 
cava inferior, and even a portion of the right auricle, may 
become filled with the growth. 

4. The most frequent form of inflammation of the kidneys, 
and the most difficult to recognize, in the early stage, is what 
has been called by Virchow — 

(a.) Parenchymatous nephritis, which occurs as a com- 
plication in very many diseases, especially in those of an in- 
fectious nature, and as a primary affection. When combined 
with haemorrhage, as is often the case, it represents the 
hemorrhagic parenchymatous form. In the first stage, that 
of cloudy swelling, the cortex is either very slightly increased 
in thickness or not at all, the consistency being somewhat 
greater than usual, and only the slight opacity of the region 
of the convoluted tubules is present to indicate the process. 
On microscopic examination of sections picked to pieces, the 
granular epithelium of the convoluted tubules appears still 
more granular, the nuclei are less distinct, and the granules 
cause these tubules to appear as if tinted with India ink. If 
upon the addition of acetic acid the granules mostly disap- 
pear, it is proof that they were albuminoid in character. 
The further the process advances the greater is the swell- 
ing, softening, and opacity of the cortex, while the former 
gray appearance of the convoluted tubules becomes more 
yellow. The granules within the cells increase, and do not 
disappear upon the addition of caustic potash or soda, their 
fatty nature being thus indicated. 
u 



210 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

Such a kidney, as a whole, is very considerably enlarged, 
flaccid, and soft, and isolated groups of convoluted tubules 
may be seen upon the surface as yellowish spots, which are 
prominent when contrasted with the perfectly opaque gray- 
ish-yellow ground substance. When the kidney is laid open 
the cortex appears thickened and swollen, projecting beyond 
the pyramidal portion. The tubules of Ferrein are to be 
recognized as gray, often as still translucent lines, while the 
region of the convoluted tubules appears opaque and is trav- 
ersed by clear, yellow streaks and spots, the fatty degener- 
ated tubules. The vessels of the cortex are usually but 
slightly injected, while those of the pyramidal portion are 
very full, so that a contrast in the color of the two regions 
becomes very apparent, especially when viewed from a short 
distance. Amyloid degeneration is frequently associated with 
parenchymatous nephritis, in which case the glomeruli, as has 
already been stated, appear upon the cut surface as translu- 
cent, vitreous, enlarged granules, and assume a brown color 
upon the addition of iodine. 

Sufficiently thin sections for microscopic examination may 
be obtained with a razor, by placing the half or even a 
smaller portion of such a kidney over the forefinger, and mak- 
ing it tense with the middle finger on one side and the 
thumb on the other. The double knife works still better, 
by which sections made perpendicularly through the cortex 
and pyramidal portion, furnish a very good general view 
when examined with a low power. It may be thus recog- 
nized that the process, even when very severe, is limited al- 
most exclusively to the convoluted tubules, which are some- 
times continuously fatty degenerated, while again (and this 
is most frequently the case) the degeneration appears in 
spots. The contrast produced by transmitted light, between 
the translucent pyramids of Ferrein and the dark appearance 
of the convoluted tubules furnishes quite a characteristic 
picture. 

The condition which is known as granular atrophy is re- 
garded by Virchow as the third stage of parenchymatous 



THE KIDNEYS. 211 

nephritis. When the epithelial cells are completely fatty 
degenerated, the detritus may be absorbed, the canals then 
naturally collapse, their tunicae propria, which undergo a 
fibrous degeneration, become united and form a hard cica- 
tricial mass, which occupies much less space than the paren- 
chyma from which it was formed, and when seen from the 
surface is much deeper than the surrounding portion. The 
projections are still relatively normal, not wholly so, because 
their frequent yellow color indicates that here also a fatty 
degeneration of the urinary tubules has taken place. The 
vascular coils in the atrophic places become obliterated, 
shrink, and finally are changed into little clumps of connec- 
tive tissue, which sometimes become impregnated with lime 
salts, and consequently appear, even to the naked eye, as 
yellowish-white points. Upon microscopic examination they 
appear black, as the lime does not allow the light to pass 
through. Upon the addition of a little hydrochloric acid the 
black mass completely dissolves with the development of gas- 
bubbles. 

(6.) By interstitial nephritis is understood an inflamma- 
tion which runs its course essentially in the interstitial (inter- 
tubular) tissue, although the proper glandular tissue also 
appears to be affected. Two forms are to be distinguished : 
(1.) the fibrous, generally of a chronic character ; (2.) the 
purulent, running an acute course. 

The first form, when total, as in the parenchymatous affec- 
tion, produces an enlargement of the cortical portion, which, 
however, presents a more uniform grayish-white appearance, 
as the contrast between the tubules of Ferrein and the region 
of the convoluted tubes disappears more or less. In micro- 
scopic sections, collections of granulation cells may be seen, 
especially about the glomeruli, and also between the urinary 
tubules which have become pressed apart. A certain num- 
ber of cases occur in which the inflammatory changes are 
situated almost wholly within the capsules of the glomeruli, 
so that they become converted into rounded masses of gran- 
ulation tissue {nephritis interstitialis glomerulo-capsularis). 



212 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

This affection must not be confounded with that first de- 
scribed by Klebs, as glomerulo-nephritis, in which the in- 
flammation is situated between the coils of the glomeruli, in 
the connective tissue which is there in small amount and 
which is provided with stellate cells. In a later stage the 
round cells become more and more spindle-shaped, then 
transformed into fibrous tissue, and thus a kind of cicatrix is 
formed within which all the tissues perish ; the epithelial 
cells become fatty, the tunicse proprise are fused, the glom- 
eruli become converted into little connective tissue clamps 
so that nothing remains but a tough fibrous tissue. The 
kidney as a whole appears atrophied, but possesses a smooth 
surface ; on section the cortical portion is especially atrophied 
and consequently of increased consistency. Remnants of 
urinary tubules are still present, which appear as yellow lines 
and points between the gray masses of connective tissue. 

The above description applies to those cases in which the 
inflammation is total, where the entire kidney is affected. 
Fibrous interstitial nephritis also occurs very frequently as a 
circumscribed affection, usually multiple, the result being a 
number of cicatricial depressions upon the surface of varied 
size, and corresponding with which wedge-shaped depressions 
of the cortex are usually seen when the section of the kidney 
is examined ; these depressed portions and less frequently a 
corresponding part of the pyramid are converted into a gray- 
ish-white, dense, fibrous (cicatricial) tissue. Microscopic ex- 
amination shows that the same changes have taken place as 
were previously described. This form of inflammation (ne- 
phritis inter stitialis chronica fibrosa multiplex) occurs in 
syphilis, and a kidney that has undergone this change ought 
always to arouse suspicions of this disease, although the latter 
can never be diagnosticated from this affection alone. Cica- 
trices which have resulted from old haemorrhagic infarctions 
bear a great resemblance to those of syphilitic origin, and 
cases will frequently occur where it will be impossible to 
make a differential diagnosis from this local condition alone. 
The appearance of the other parts of the body must then be 



THE KIDNEYS. 213 

taken into consideration. In other cases the local affection 
furnishes a point for differentiation. The syphilitic scars are 
always of a gray color, while brownish, greenish, or blackish 
flakes of blood-pigment remain for a long time in those re- 
sulting from haemorrhage. 

Although circumscribed interstitial nephritis occurs most 
frequently in the cortical portion, still it is not altogether 
absent from the pyramids, where, for instance, according to 
Virchow, the gray fibromata arise from such a circumscribed 
inflammation, as the urinary tubules may be followed into 
them. These vary in size from that of a millet-grain to that 
of a pea, and may be easily distinguished from tubercles by 
the absence of cheesy degeneration. The interstitial inflam- 
mation is frequently situated within the papillse (nephritis 
interstitialis papillaris) apparent by their gray color. 

The pyramids are also a favorite seat for cysts caused by 
chronic interstitial inflammation. These are large or small, 
the former being produced by the confluence of smaller ones, 
as may be recognized by the projections upon their walls. 
In the earlier stages of the affection, several small cystic en- 
largements may be seen with the microscope, situated along 
the course of a single tubule, the interior of which is filled 
w T ith a peculiar glistening gelatinous mass. 

The second form of interstitial inflammation is what is 
known as purulent interstitial nephritis, which tends from 
the beginning to interstitial suppuration. Certain varieties 
of this affection constitute metastatic nephritis, which is 
produced by septic emboli and is characterized b}^ the ap- 
pearance of metastatic abscesses. These rarely attain a large 
size and are usually situated in the cortical portion, though 
sometimes in the pyramids. In the latter case, however, 
they are never found within the apices of the papillae, but 
rather in the middle and outer portions. The contents of 
the little abscesses are not composed of actual pus, but of 
disintegrated, fatty degenerated glandular tissue. It often 
happens in this affection (for instance in connection with en- 
docarditis ulcerosa) that it is possible to recognize micrococci 



214 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

in the centre of each abscess ; they may lie in the glomeruli, 
in other vessels, in the urinary tubules, or in the interstitial 
tissue. When sections made with the double knife are first 
soaked in absolute alcohol and ether, then in acetic acid, and 
finally are tinged with aniline-yiolet, the micrococci will 
assume a beautiful blue color, while all the fat, which is 
produced in large quantities in the surrounding tissues by 
parenchymatous inflammation, is dissolved. To this class 
belong a number of varieties of inflammation which result 
from disease of the urinary tract, and which produce at the 
outset changes in the pyramidal portion. Such alterations 
consist of small yellow lines which often contain spherical 
enlargements, and which follow the course of the urinary 
tubules from the apices of the papillae towards the periphery. 
On the surface of the papillae a tough, grayish, diphtheritic 
infiltration is often found. A little later the cortical portion 
becomes involved, when the striped appearance of the ab- 
scess is less marked, and it assumes more the form of a cir- 
cumscribed collection of pus. 

It has already been stated that the abscesses appear on 
the surface as small yellow points of the size of a millet- 
grain, and are arranged in small groups. On examining the 
surface of the section, they may usually be followed through 
the cortical into the pyramidal portion ; still it is not always 
possible to discover that the affection of the two portions is 
continuous. When larger abscesses have formed in the re- 
nal tissue they may rupture into the calices, when a suppu- 
rating ulcer is formed Qphthisis renalis purulent a). It was 
precisely in this affection, spreading from the pelvis to the 
kidney, and associated with marked alteration in the mucous 
membrane of the former and of the calices (hence called 
pyelo-nephritis), that Klebs first recognized the constant ap- 
pearance of lower organisms. The disease almost always 
accompanies inflammatory and often actually diphtheritic 
processes in the bladder, being considered as the direct re- 
sult of a wandering of the organisms along the ureters and 
renal pelves into the urinary tubules. The results here, as 



THE KIDNEYS. 215 

in case of embolic affection, are not abscesses properly speak- 
ing, but the pus is mingled with the products of fatty and 
broken-down epithelial cells, and frequently there may be no 
real pus formed at all. Careful examination shows that the 
urinary tubules are completely plugged, and even distended, 
with micrococci ; that the epithelial cells, not only of these 
but of the neighboring tubules, are fatty degenerated, and 
that only finally a zone of interstitial suppuration surrounds 
these centres. 

There is, however, another affection quite similar to the 
preceding, as far as the local trouble is concerned, and which 
agrees etiologically also, as micrococci are always found in 
the centres of inflammation. In certain diseases, especially 
in those of a septic nature, and when moreover there is no 
local cause for metastasis, yellowish, or frequently yellowish- 
brown, linear or round spots of inflammation are seen within 
the pyramids and especially in the papillae (nephritis pajnl- 
laris diphtheritica') ; these are very similar to those already 
described, and upon microscopic examination are seen to be 
composed of three constituents, — micrococci which lie within 
the tubules or vessels, fatty degenerated epithelial cells of 
the former, and an inflammatory infiltration of the surround- 
ing tissue. 

Such preparations deserve careful attention, as they are 
especially fitted to illustrate the difference between micrococci 
and fat granules. The former are small and uniform in size, 
lying at equal distances from each other, and present a sharp 
and dark contour ; the fat granules on the contrary are of 
unequal size, tying at unequal distances from each other, and 
disappear when treated with glacial acetic acid, alcohol, and 
ether. It is clear that in this affection the organisms come 
from the blood, as the urinary tract is unaltered while the 
glomeruli and other vessels are filled with micrococci. 

(<?.) The last form of renal inflammation to be considered 
is the catarrhal (nephritis catarrhalis), which affects princi- 
pally the trunks of the straight tubules (tubes of Bellini"). 

The bundles of straight tubules within the pyramids and 



216 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

also the tubules of Ferrein appear widened, their translucent 
gray is changed into an opaque gray or grayish-white color, 
and it is possible to press out of the papillae a large quantity 
of milky fluid of a cloudy gray or grayish-yellow color ; with 
the microscope this is found to contain numerous large and 
small cells, free nuclei and detritus, with only comparatively 
few cells of ordinary size. It is possible to distinguish by 
examining this fluid, the gray color of the papillae caused by 
catarrhal inflammation from that due to the interstitial form, 
as in the latter affection it is possible to press out only a very 
small quantity of fluid and cells. 

In connection with the inflammatory processes may be 
mentioned the microscopic masses contained in the urinary 
tubules, and known as casts (hyaline casts, incorrectly called 
fibrinous). They occur both in the straight and looped 
tubules, and those in the latter sometimes undergo amyloid 
degeneration. They are often best seen with a low power, 
when they may be recognized by their peculiar fatty lustre. 
The casts extend into the cortical portion only in extreme 
cases. 

5. The different forms of renal infarction are to be con- 
sidered in concluding the subject of the inflammatory pro- 
cesses, especially those of the papillae. Four forms are to be 
distinguished, — the lime, the uric acid, the haematoidine, 
and the bilirubine infarction. The first occurs only in adults, 
the second and fourth in children only, and the third in both, 
though under very peculiar conditions in adults. 

(a.) Lime infarctions appear in the form of white lines, 
which radiate from the apex of the papilla and extend as 
far as the middle of the pyramid, or even further. Upon 
section, especially when made transversely (with the double 
knife), very small lime granules appear, either free in the in- 
terior of the tubules, or, as is more frequently the case, de- 
posited in the walls of the same. Upon the addition of hy- 
drochloric acid they become dissolved with the evolution of 
gas. The deposition of the granules takes place not only 
within the straight tubules but also in the looped ones, and 



THE KIDNEYS. 217 

on this account these kidneys are particularly fitted to show 
the loops of Henle in the easiest manner possible. Lime in- 
farctions always indicate interstitial inflammation. 

(5.) Uric acid infarctions occur only in very young chil- 
dren, usually in the first week of life, still they have been 
observed in the sixth week, and even later. Their presence 
has an important medico-legal bearing, as they are found 
almost exclusively in children who have breathed. These 
infarctions appear as yellow, brick-red, or yellowish-red lines 
extending from the papillae ; similar yellow lines are only 
rarely seen in the cortical portion. By tearing apart a 
small bit of the papilla, or pressing the epithelium out of the 
straight tubules, it will be seen that they are completely 
filled with a mass that appears either light or dark-brown by 
transmitted light, and yellow or rose-red by reflected light. 
These masses are dissolved by the addition of hydrochloric 
or acetic acid, crystals of uric acid being formed upon the 
evaporation of the resulting solution. When examined with 
the microscope, the mass is found to be composed of glob- 
ules of varied size, often in pairs, and covered upon their 
surface with thorn-like projections (urate of ammonia). The 
other uric acid salts (soda) occur less frequently. The 
urates are found exclusively in the urinary tubules. 

(c.) Haimatoidine infarctions appear in adults only under 
very peculiar conditions (after transfusion of blood from the 
lower animals, burns, etc.). Masses are then found in the 
papillae, filling the tubules, which appear like brown lines, 
and are composed, in recent cases, of course, of blood corpus- 
cles. In cases of long standing they consist of blood pig- 
ment. According to Virchow the haematoidine infarctions 
in the new-born, present a clear brown, brownish, or reddish- 
brown color, and consist of a deposition of yellowish-red or 
reddish-brown granular or crystalline haematoidine, which 
appears both in the canal of the tubules and in their epi- 
thelial cells. The coloring matter is due to small hemor- 
rhages. 

(c?.) Bilirubine infarctions are of more frequent occur- 



218 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

rence, either alone or combined (the usual form) with uric 
acid infarction. They occur only in the new-born, in those 
that were jaundiced. The pigment has the form of rhombic 
tablets, of fine needles often arranged in arborescent or stel- 
late groups, and of clumps which occur both in the interior 
of the tubules, in the epithelial lining, in the intertubular 
tissue, and especially in the vessels. Their principal seat is 
in the papillae, but in cases of great intensity they are not 
wanting in the cortical portion. (The same crystals appear, 
though not constantly, in the blood, and in fact in all the 
organs.) The well-known reaction of biliary coloring matter 
is very readily obtained from them. It is only necessary to 
treat a little piece of the affected tissue with liquor potassae 
(under a covering glass), then washing away the excess of 
the fluid with water, finally add nitric acid of the proper 
strength, in order to produce successive rings of green, blue, 
violet, and red extending from the periphery toward the 
centre. The bilirubine infarctions may be distinguished 
from those due to haematoidine by the fact that the former 
occur very irregularly, and as a rule only upon single papillae, 
while the latter affect all the papillae equally. 1 In adults, 
yellow, green, brown, and black granules of bile pigment 
occur, both in the convoluted tubules and in the straight 
ones, combined with chronic inflammation, in cases of icterus 
of long standing. 

(<?.) Nephritis urica also depends upon a deposition of 
crystalline masses, and is' due to gout. Small, chalky, white 
spots or lines may be seen in the pyramids or (less fre- 
quently) in the cortical portion. Upon microscopic examina- 
tion, they are found to be composed of masses of crystalline 
urate of soda, which appear not only in the form of very fine 
needles, as in the joints, but also in the form of large crystals 

1 In distinguishing haematoidine and bilirubine infarctions the question of the 
identity of the chemical composition of those two bodies is not considered ; 
their origin only is indicated by the name, haematoidine originating from the 
effused blood by a direct local change, while bilirubine is excreted from the 
blood, where it is already present as biliary coloring matter. 



THE KIDNEYS. 219 

(rhombic prisms). Chronic interstitial inflammation exists 
around them. Whenever these changes are found to exist in 
the kidney, the examination of a number of joints, especially 
that of the great toe, for gouty deposits, must never be omit- 
ted. 

6. Tuberculosis occurs in two forms in the kidney ; some- 
times as a disseminated, secondary affection, which has its 
favorite seat in the cortex, and again as a localized and pri- 
mary tuberculosis, which takes its origin in the calices and 
apices of the papillse. In the first form submiliary and mil- 
iary nodules are scattered through the cortex, especially on 
the surface. Upon the surface of the section the nodules 
often appear arranged in a narrow row following the direc- 
tion of the vasa interlobularia ; as changes (fatty metamor- 
phosis) in the neighboring tubules are usually connected with 
them, the appearances may be easily mistaken for small 
haemorrhagic infarctions. The presence of the minute gray 
nodules prevents any mistake. Leucaemic and typhoid nod- 
ules, which are rare, resemble these tubercles. 

The second form, which has its principal seat upon the 
apices of the papillae, shows less plainly its origin from sep- 
arate tubercles. A yellow, cheesy mass of variable size, soft- 
ened and disintegrated upon the surface, and in which separ- 
ate tubercles are no longer to be seen, takes the place of the 
apex of the papilla, and occupies the contiguous portion of 
the calyx. Isolated tubercles occur at the periphery, dimin- 
ishing in size and number the more distant they are, and 
extend, in cases of long standing, to the outer surface of the 
kidney, where they may be recognized, but, of course, can- 
not be distinguished from those occurring in the disseminated 
form. Those lying next to the cheesy mass are yellow, and 
even cheesy ; those farther off are gray, translucent, in other 
words, perfectly fresh. Since the disintegration of the nodule 
continually extends from within outwards, larger and larger 
portions of the pyramidal substance, and, finally, the whole 
pyramid, and even a portion of the cortex, may be destroyed. 
As the superficial portions of the cheesy mass become do- 



220 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

taclied, the calyx, which was at first narrowed, now becomes 
widened (phthisis renalis tuberculosa). This affection is 
frequently associated with a similar one of the urinary tract 
(bladder) and sexual apparatus. 

7. Gummata are seldom met with. They appear when 
recent, in the form of nodules, which vary in size from that 
of a millet-grain to that of a pea, are of a uniform yellow 
color, have a firm, elastic consistency, and are situated within 
a fibrous tissue, produced by chronic interstitial inflammation. 
Upon microscopic examination one finds the usual granulation- 
like tissue rich in cells, with fatty degeneration of the latter. 

8. The new formations which occur here, include adeno- 
mata, carcinomata, and sarcomata (both primary and second- 
ary), fibromata, and, more rarely, others, such as lipomata, 
angiomata, etc. 

Adenomata appear in the form of yellowish nodules, the 
size of which varies from that of a millet-grain to that of a 
bean. They frequently contain numerous small cysts, and 
are surrounded by a connective- tissue capsule. Upon micro- 
scopic examination the urinary tubules are found to be wid- 
ened and furnished with offshoots, their cells frequently 
fatty ; haemorrhages are often situated within the canals, giv- 
ing rise at times to a brownish-red color. 

Carcinomata and sarcomata are to be recognized here by 
the rules already laid down ; still it ought to be mentioned, 
that a mixed form of the two (carcinoma sarcomatosum) oc- 
curs in the kidney, the diagnosis of wmich is extremely diffi- 
cult, and can only be made by a very careful examination of 
hardened specimens. The growth of malignant tumors of 
the kidney into the renal veins, and through these into the 
inferior cava, etc., has already been referred to. 

4. Examination of the Calices, Pelves, and Ureters. 

Certain affections of the calices and pelves, which occur 
in connection with diseases of the kidney, have already been 
considered. (Edematous swelling of the mucous membrane 
with haemorrhage occurs in many varieties of renal inflamma- 



THE KIDNEYS. 221 

tion. Haemorrhage occurs here, especially in haemorrhagic 
small-pox, etc. ; purulent and diphtheritic inflammation, as 
elsewhere. It is worthy of mention, that while diphtheritis 
is present, both in the bladder and pelves of the kidneys, it is 
replaced by a simple, generally haemorrhagic inflammation of 
the ureters, so that it is possible to recognize a continuity 
of the inflammation, but not of the diphtheritis. Tuberculo- 
sis is usually combined with phthisis renalis, and possesses 
similar appearances ; a thickening of the whole wall, cheesy 
degeneration of the surface, and gray tubercles in the mucous 
membrane about the cheesy places and at remote points in 
the more advanced cases. Cheesy ulcerations begin both in 
the pelvis of the kidney and in the ureter as lenticular ulcers, 
which are small, round, and either isolated or arranged in 
groups. These will be more minutely described in connec- 
tion with the affections of the bladder. 

Chronic inflammation of the calices, which is frequently 
combined with a reticulated or linear thickening of the mu- 
cous membrane, is most frequently met with as a result of 
an irritation caused by concretions, either in the form of small 
brittle masses (gravel) or larger compact stones. Cases 
occur in which the whole cavity of the pelvis and calices is 
filled with one continuous mass of concretion. The character 
of the stones varies greatly according to their composition. 
Very compact ones of a dark brownish-yellow, or grayish 
color with a mulberry-like surface, are composed of the salts 
of oxalic acid, oxalate of lime calculi. Urate calculi, com- 
posed principally of uric acid salts, are usually smooth or 
but slightly uneven, of a clear brownish-yellow color, fre- 
quently streaked and of medium consistency ; finally, those 
composed of phosphates and carbonates are very soft, white, 
and chalky. As the latter are usually produced as a result 
of catarrh, or the decomposition of urine accompanying it, a 
layer of phosphates is frequently met with covering other 
stones. The excretion of oxalates and urates, apparently 
depends upon changes in the blood, and they may alternate 
in layers, so that under proper conditions all possible forms 



222 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

of precipitates may be found upon one stone. It has already 
been mentioned that purulent inflammation of the urinary 
tract and kidneys (nephritis calculosa) may be produced by 
urinary calculi. It is necessary to add that they often pro- 
duce dilatation of the tract, concerning which a detailed de- 
scription will be directly given. 

It may be first mentioned that in rare cases a multiple 
cystic formation is found connected with chronic inflamma- 
tion of the mucous membrane of the pelvis and ureter. The 
little cysts are often present in large numbers, their average 
size varying from that of a pin's head to that of a millet- 
grain. They project far above the mucous membrane, and 
usually contain a perfectly clear and often colloid material. 
Nothing definite is known in regard to their origin. 

One of the most important affections of the upper portion 
of the urinary tract is dilatation, resulting from a retention 
of urine, caused by an obstruction to its discharge. Accord- 
ing to the situation of the obstruction, which may be at a 
greater or less distance from the kidney, the ureter, pelvis, 
and calices, or only the two latter are involved, the kidney 
being affected in both instances (hydronephrosis). The kid- 
neys are converted in extreme cases into fluctuating sacks, in 
which only small portions of glandular substance are seen 
here and there, forming a part of the walls. The calices and 
pelvis form one large cavity, and the ureter, when the ob- 
struction is situated near the bladder, is converted into a 
canal as large as the finger. A less degree of the affection is 
indicated by a slight fullness of the calices and pelvis, and 
also by more or less flattening of the otherwise pointed, 
wedge-shaped papillae. Between the two extremes all de- 
grees of the affection occur. In all cases of hydronephrosis 
of any severity, the kidney is very anaemic, firm, tough, and 
in a state of chronic interstitial inflammation. The destruc- 
tion of the parenchyma by atrophy begins in the papillae, 
and passes from here outwards. 

The narrowing of the tract producing the hydronephrosis, 
is usually caused by external pressure upon the ureter, or by 



THE PELVIC VISCERA. 223 

obstruction of the latter by a stone. In other cases no such 
cause exists, and it is then often found that the ureter leaves 
the renal pelvis at an acute angle, so that a valve-like pro- 
jection from its wall becomes possible, which is sufficient to 
cause an obstruction at the beginning of the ureter. Unilat- 
eral hydronephrosis usually presents an extreme degree of 
degeneration, while the other kidney assumes a portion of its 
function by compensatory hypertrophy. The dilatation is 
bilateral in many diseases of the uterus, especially in car- 
cinoma, in which affection the ureters are often included 
within the cancerous growth. When this condition of things 
is found, it is necessary to examine the size of the ureters by 
the rules already laid down, before removing the kidneys. 

Finally, a congenital anomaly of the kidneys and of the 
upper portion of the urinary tract sometimes occurs, which 
consists in a doubling of the parts, and sometimes affects the 
ureters alone, and again the pelvis and kidneys. In the lat- 
ter case a wide glandular septum is usually seen upon making 
a section, separating the two ureters, but in such a way that 
it belongs more to the one than to the other. In rare cases 
a complete division of the kidney also occurs. 



5. THE PELVIC VISCERA. 

The examination of the bladder and urethra follows that 
of the kidneys, and as the former should only be removed 
in connection with the sexual apparatus and rectum, the pelvic 
viscera as a whole are now to be considered. After the rela- 
tive position of the organs has been accurately determined, 
and especially the height of the uterus when that organ may 
happen to be enlarged, the examination begins with the con- 
sideration of the bladder, its size, form, and degree of fullness. 
It is to be drawn somewhat away from the symphysis, and 
a longitudinal incision is made in its anterior wall that the 
character and quantity of its contents may be determined. 



224 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 
(tf.) THE CONTENTS OF THE BLADDER. 

The color of the urine varies, as is well known, from that 
of the clearest amber to a yellowish-red, brownish-red, or 
even perfectly black. If the' latter shades are produced by 
drugs, as senna or rhubarb, the color disappears upon the 
addition of a mineral acid, otherwise it is due to an admix- 
ture of blood. When this is present in small quantity, and 
when the corpuscles have been so long soaked as to be de- 
prived of their pigment, a cherry-red color results. A uni- 
form discoloration indicates diffused coloring matter, while 
that which increases towards the bottom of the vessel by 
standing, points to a fresh admixture of blood. The point 
may be very easily and accurately determined by microscopic 
examination. The stroma of the soaked blood corpuscles may 
often be recognized as pale spheres possessing a delicate con- 
tour. Biliary coloring matter in the urine is easily recog- 
nized by the yellowish-red or brown color, and by the reac- 
tion with nitric acid. Granular or crystalline bile pigment 
adhering to cells or casts is occasionally met with, both in 
jaundiced children and in adults. 

Pus may be mixed with the urine in varying quantity. 
When only a very small amount is present the most super- 
ficial layers of the contents of the bladder may be perfectly 
clear, while a thick yellow pus is found at the fundus, when 
the body is in the usual dorsal position. When the bladder 
contains but little fluid, the latter has a more or less purulent 
quality. The pus corpuscles may be easily recognized with 
the microscope. A cloudy, dirty, grayish-yellow mass, which 
becomes brown when mixed with blood, may be present in- 
stead of pus, the ammoniacal odor of which indicates that 
it has already commenced to decompose. Yellow sand-like 
concretions are often to be found floating in this material. 
Large numbers of the different forms of micrococci and bac- 
teria may be seen under the microscope. 

The different forms of hyaline casts may be briefly men- 
tioned among the admixtures in the urine which change its 



GENERAL METHOD OF REMOVAL. 225 

gross appearances but slightly. These are sometimes per- 
fectly transparent ; again, tinged with yellow and studded 
with blood corpuscles, fatty cells, bacteria, etc. ; also with 
small numbers of pus corpuscles, and in rare instances with 
cells from various tumors. 

The principal solid sediments consist of urate of soda, which 
appears in the form of small amorphous granules, and of pure 
uric acid in the form of whetstones or sheaves ; colorless 
triple phosphates in the form of a coffin-lid (ammoniaco- 
magnesian phosphates) are also met with, and finally, the 
envelope form of oxalate of lime. What has been said in 
regard to renal calculi applies in general to those of the 
bladder. In order to ascertain the above mentioned admix- 
tures, the urine is to be allowed to stand for a while in a 
conical glass, the supernatant fluid is then to be poured off, 
and the remaining portion used for examination. 

(6.) GENERAL METHOD OF REMOVAL. 

After the urine has been removed the rectum is to be sep- 
arated from the colon, and the latter drawn somewhat up- 
wards (when the contents of the large intestine are thin and 
abundant a double ligature should be applied before the sep- 
aration is made). The rectum is then to be drawn forwards 
with a good deal of force, and a large knife is deeply inserted 
perpendicularly between the rectum and sacrum, to separate 
with a sawing motion the loose connective tissue from the 
latter along the linese arcuatse as far as the os pubis. The 
separation of the rectum from behind is to be continued by 
a few horizontal cuts extending to the anus. The rectum is 
now grasped with the last three fingers of the left hand, 
while the index finger of the same is placed in the opening 
in the bladder, then drawing firmly all the pelvic organs 
upwards and backwards, they may be removed by cutting 
through their attachments to the walls of the pelvis, keeping 
the knife close to the symphysis in front. Ity depressing the 
handle of the knife backwards and to the right when cutting, 
especially at the bottom of the symphysis of the male, the 

15 



226 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

whole prostate and even a portion of the urethra may be re- 
moved in connection with the bladder. 

In removing the penis, the abdominal incision may be 
extended as far as its middle, the posterior attachment of 
the corpora cavernosa separated, and the organ be then cut 
through subcutaneously as far forwards as one wishes. If it 
be desirable to preserve the attachment of the urethra to the 
bladder (strictures, false passages), the penis is cut through 
in the manner just mentioned, before the pelvic organs are 
removed. It is then to be separated from the attachments 
about it, especially to the pubes, and drawn backwards under 
the symphysis into the pelvis, from which it may be removed 
with the organs in the manner already described. The testes 
can be examined very easily without injury to the scrotum, 
by enlarging the spermatic canal somewhat from the inside 
and pressing them out from below. If it is desirable to allow 
them to remain attached to the pelvic organs, both are to be 
pressed out of the spermatic canal in this manner, and the 
vasa deferentia separated from the sides of the pelvis as far 
back as the bladder, before the pelvic viscera are removed. 

The female sexual organs, including the entire urethra, 
vagina and nymphse, rectum and anus, may be removed, as 
before, by detaching the rectum and drawing the organs 
forcibly backwards. When it is desired to remove the outer 
genitals also, the pelvic viscera are first to be wholly detached 
from the sides of the pelvis, the legs are to be separated, and 
the external genitals are to be enucleated to such an extent 
as may be necessary. They are now detached from the pubes 
by carrying the knife under the symphysis in the longitu- 
dinal axis of the body, and separating them in front and on 
the sides. When this has been done, the genitals are to be 
drawn backwards beneath the symphysis into the pelvis, the 
left index finger is to be placed in the anterior orifice of the 
vagina, instead of in the incision in the bladder, then the 
viscera are to be raised up, as has been already described, and 
separated from the integument behind the anus. After the 
organs are removed, they are to be placed in their normal 



THE BLADDER AND URETHRA. 227 

position, the bladder uppermost, and examined separately, 
from above downwards, in their natural order. 

(tf.) EXAMINATION OF THE BLADDER AND URETHRA. 

The section of the urethra and bladder is made from the 
former into the latter ; in the male the corpora cavernosa 
should be separated through the septum. The incision into 
the bladder must terminate in that already made. 

1. The Bladder. 

(#.) General Morbid Conditions. 

The distention of the bladder naturally depends upon its 
contents ; still there are cases where it is rather owing to 
some mechanical obstruction, outside the bladder, to the dis- 
charge of urine, or to muscular paralysis of the bladder itself. 
In the former case the walls are thickened also, to be diag- 
nosticated from the appearance of the inner surface, as the 
bundles of unstriped muscular fibre are thickened and be- 
come very prominent, trabecular hypertrophy, while between 
them very deep pockets are often situated (diverticula). 
Thickening of the vesical mucous membrane alone is pro- 
duced by oedematous swelling, which may result from many 
kinds of inflammation of the bladder itself, or in its imme- 
diate vicinity. 

The shape of the bladder is frequently altered when the 
place where the urachus formerly opened is made prominent 
as a small conical projection. This represents the lowest 
degree of the more marked deformity, where the urachus re- 
mains open to a greater or less extent. Another variation 
in shape is produced by small pocket-like projections of the 
walls, diverticula, which are usually situated on the posterior 
wall and are partly congenital, and partly acquired in the 
manner already described. 

In most cases the color of the mucous membrane is pale 
gray, though injected veins are often prominent in the tri- 
gonum, and near the origin of the urethra, especially in old 
females. In recent inflammation the color becomes red, when 



228 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

very severe a dark red, but it is seldom uniform over the 
whole surface, being often confined to the projecting muscu- 
lar bundles, and always more marked here than in the sur- 
rounding portions. A slaty color indicates chronic inflam- 
mation, and is distributed in like manner. 

The consistency of the vesical walls increases with the 
thickness. The mucous membrane if oedematous is often 
soft and gelatinous. 

(3.) Special Morbid Conditions. 

Haemorrhages are the first affections to be mentioned, and 
may be the accompaniments of inflammatory processes, or 
may result from a general hemorrhagic diathesis (phosphorus 
poisoning, etc., endocarditis ulcerosa). 

Inflammation of the bladder is either simply catarrhal, 
when the mucous membrane is swollen and more or less red- 
dened, or it is purulent with intense reddening, swelling, and 
a purulent secretion ; it may also he, fibrinous (more rarely), 
with the formation of a false membrane easily removed, or 
diphtheritic and necrotic, which produces different appear- 
ances, according to the extent and degree. In recent cases 
gray deposits are occasionally seen tightly adherent to the red- 
dened and hemorrhagic mucous membrane of the trigonum, 
and to that covering the muscular bundles of the fundus. 
In more advanced cases these are increased both in area and 
in depth, and on section a gray infiltration within the mucous 
membrane may be seen. In the most severe and certainly 
in the rarest cases, the whole mucous membrane may become 
necrotic, and separate as a complete cast from the muscular 
tissue. In such cases it is usually studded with concretions 
and consequently has a sandy feel. 

Tuberculous affections of the cystic mucous membrane 
possess great interest and have a characteristic appearance. 
The two forms which have often been mentioned occur here 
also, the disseminated, acute miliary tuberculosis rarely, but 
the localized form leading to the formation of ulcers is met 
with more frequently. In relation to the first, it is to be 
remembered that lymphoid follicles exceptionally occur, which 



THE BLADDER AND URETHRA. 229 

may be easily mistaken for tubercles. They may be distin- 
guished from tubercles by their size, frequent regular dis- 
tribution, and the absence of any trace of cheesy degeneration 
in their centre ; their appearance without other tuberculous 
affections is also of importance, and the presence of vessels 
within them is easily recognized by the microscope. 

The second form is especially interesting, as the tubercles 
in the bladder tend to form in a typical manner the char- 
acteristic so-called lenticular ulcers. These are the ulcers 
which have been already described as occurring in the 
bronchi, being characterized by a flat cheesy base and a sharp 
jagged border, within which intact nodules are situated. 
The mucous membrane around them is often reddened, and 
they frequently coalesce, forming larger ulcers which have a 
scalloped outline. The favorite seat of these ulcers is also 
the trigonum and fundus. They occur only in extensive 
tuberculous affections of the urinary and sexual apparatus, 
especially of the male. 

Tumors of the bladder are relatively rare, especially the 
primary form. Secondary carcinoma of the posterior wall in 
cases of carcinoma uteri, is the most frequent. In the begin- 
ning, merely rounded projections of the mucous membrane 
are to be seen ; later, however, small nodular tumors appear 
upon the surface and may finally attain a considerable size, 
and also break down by the extension of the ulcerative pro- 
cess from the vagina, thus producing a vesico-vaginal fistula. 
Sometimes the secondary nodules are situated around the 
opening of one of the ureters, so that hydronephrosis results ; 
still obstruction of the ureter by tumors is more frequent 
when they are situated behind or near the bladder. 

Among the primary tumors, besides the soft cancers which 
appear in the form of large nodules, there are the so-called 
villous cancers (carcinoma papillosum). These send projec- 
tions into the bladder in the form of papilla), which are often 
arborescent, and contain cylindrical cancer cells and numer- 
ous vessels* so that vesical haemorrhage often results Their 
favorite seat is on the trigonum Lieutaudii. The ends of the 



230 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

papillae often become enlarged by incrustations of uric acid 
salts, when they become of a light yellow color, and float very 
freely when water is poured upon them. They must not be 
confounded with condylomata, which also possess villi. The 
means of distinguishing them were mentioned in treating of 
cancer of the skin. 

Eupture of the bladder, besides resulting from tubercu- 
lous and carcinomatous ulceration, may also be produced by 
direct mechanical injury, especially during child-birth and in 
the operations attending it. It usually follows partial ne- 
crosis of the posterior or often of the anterior wall only, where 
it presses against the symphysis. Such an injury and con- 
sequent necrosis is followed by a violent gangrenous inflam- 
mation of the connective tissue about the bladder {pericystitis 

gangrenosa). 

2. The Urethra. 

Many affections of the urethra are similar to those of the 
bladder, and not unfrequently diseases in the latter extend 
into it, especially into the posterior portion of the male 
urethra. Only those alterations therefore which are peculiar 
to this tract will now be considered. An affection of the 
blood-vessels, which appears more particularly in females, has 
been incidentally mentioned in considering the bladder ; it 
consists in a dilatation and injection of the veins at the neck 
of the bladder, and of those of the urethra, the so-called 
vesical varix. Simple thrombosis (even phlebolites) and the 
inflammatory form (thrombophlebitis) may occur, followed 
by embolism of the lungs. 

In geneial, the more complex male urethra is much more 
subject to disease than that of the female. One of the most 
important is narrowing, stricture of the urethra. It may 
occur in all degrees, from the very slightest contraction to 
an almost complete closure, through which it is next to im- 
possible to pass the smallest probe. The stricture is usually 
situated within the membranous portion, and a fibrous thick- 
ening (from chronic inflammation) or cicatrices ^frorn ulcers 
of the mucous membrane) may be observed, both at the place 



THE PROSTATE. 231 

where the stricture is situated and in its immediate vicinity. 
Lacerations are often present in cases of stricture, false 'pas- 
sages being made by improper catheterization. Some of 
these may be recent, while others are of long standing and 
already partially healed. The same thing happens when the 
canal is narrowed by enlargement of the prostate, and one 
then sees, especially in the prostatic portion, long canals 
which run outside the urethra and into the prostate. Such a 
laceration may cause suppuration about the urethra within 
the gland (peri- urethritis), and when the abscess (peri- 
urethral) discharges into the urinary tract, an extensive gan- 
grenous inflammation of the cellular tissue may result, owing 
to the effect of the urine upon the tissues. Such an effect 
may also be brought about by anything which causes per- 
foration of the urethra. 

Of the remaining affections tuberculosis may be borne in 
mind. This occurs onty in the male, and has the same ap- 
pearance as in the bladder, but more frequently causes exten- 
sive destruction of the walls, especially in the pars prostat- 
ica. The wider female urethra is more frequently the seat 
of tumors, of which the condylomata are most frequently 
found. 

(cZ.) THE PROSTATE. 

The prostate is to be examined by dividing it transversely 
in front of the colliculus seminalis ; variations in its size are 
very common, as it is frequently enlarged, especially in old 
men. The enlargement may involve both lateral lobes, and 
is then of comparatively little importance, or it may affect 
the so-called middle lobe, which, as is well known, first ap- 
pears in consequence of its enlargement. It then projects 
more or less into the neck of the bladder, and may be the 
cause of hypertrophy and catarrh of the bladder, and of 
lacerations of the urethra from catheterization (false pas- 
sages). 

Atrophy may be the result of chronic inflammatory proc- 
esses, and also occurs in old subjects. In such cases the sec- 
tion is very frequently found to be covered with black or 



232 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

brown pigment, as though sprinkled over with snuff. These 
little brown concretions, the so-called prostatic calculi, may, 
under certain conditions, attain a very considerable size, and 
in part show the amyloid reaction. 

Purulent inflammation (prostatitis apostematosa) affects 
sometimes only one lobe, and again, the whole organ ; all 
degrees may be found between abscesses the size of a pea 
and suppuration involving the whole gland. In the latter 
case, the discharge may take place on either side, especially 
on the posterior. 

When tuberculosis exists in the urinary organs, the pros- 
tate, as a rule, is also affected. In recent cases, only small, 
cheesy nodules are seen, and fresh, gray tubercles are sit- 
uated in their neighborhood. Later the cheesy masses in- 
crease in size, soften in the centre, and large cavities filled 
with soft, cheesy material, are t then seen ; they are sur- 
rounded by a firm, dry, yellow mass, around which an in- 
distinct tubercular eruption is frequently met with. 

Hypertrophy may be due to either an increase (hyper- 
plasia) of the glandular portion or of the interstitial tissue. 
The former is soft, grayish-yellow, and a fluid rich in cells 
may be pressed (adenoma) from the section ; when the cut 
surface is examined the ducts of the gland are seen provided 
with conical projections. No fluid can be pressed from the 
latter form, and upon section, only the fibro-muscular inter- 
stitial tissue is seen to be increased (fibromyoma). The two 
forms may occur combined. 

Tumors of a carcinomatous or sarcomatous nature also 
are met .with, though but seldom. 

(e.) THE VESICUL^ SEMINALES AND THE YASA DEFE- 

EENTIA. 

In order to examine the vesiculat seminales, the floor of 
the fossa between the rectum and bladder is to be turned 
upwards, so that the prostate may lie upon the left index 
finger, the posterior wall of the bladder is then to be strongly 
drawn away with the thumb from the anterior wall of the 



TESTIS, EPIDIDYMIS, AND SPERMATIC CORD. 233 

rectum, which is held by the middle finger. The two sacs 
will then be seen as two long projections behind the neck of 
the bladder. They are then opened for examination by 
making a longitudinal incision through them. The ends of 
the vasa deferentia may be easily seen at the same time, and 
may be slit open with a pair of small scissors. 

The contents of the vesiculse seminales are subject to many 
variations, both in respect to quantity and composition. It 
is not always possible to find spermatozoa, even when the 
contents of the vesicles are present in large quantities ; in 
their stead are round cells, which contain, especially in old 
subjects, and cachectic individuals, abundant brown pigment- 
granules. These may give to the whole fluid a brown color, 
apparent to the naked eye. The consistency of this fluid is 
frequently thick and gelatinous, in which case round or cylin- 
drical colloid masses, often containing empty spaces, are 
found with the microscope. Inflammation is rare, but chron- 
ic, fibrous, and purulent forms occur. The changes most 
frequently found both in the vesiculse seminales and their 
excretory ducts, are those produced by tuberculosis, which 
presents the same characters here as in the ureters, and is 
associated with general genito-urinary tuberculosis. In an 
early stage the innermost layer of the mucous membrane is 
of a yellow color, and covered with a thin layer of cheesy 
material. Later, the canal becomes filled with this mass, and 
the yellow color (cheesy degeneration) of the wall extends 
further in. At the same time a chronic inflammation is set 
up at the periphery, giving to the connective tissue a fibrous 
character. 

(/.) THE TESTIS, EPIDIDYMIS, AND SPERMATIC CORD. 

In examining the testes their position is first to be noted. 
As is well known, it not unfrequently happens that either 
one or both do not lie in the scrotum but in the abdominal 
cavity, or somewhere within the spermatic canal {monorchia 
cryptorchis). In the latter case it is often possible to dolor- 
mine their position by feeling upon the outside. In such 



234 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

instances their size is almost always abnormal, being usually 
small, and the tissue atrophied; sometimes, however, they 
are enlarged. Such retained testes are liable to be the seat 
of various kinds of tumors. 

1. The Spermatic Cord and Tunica Vaginalis Propria. 

The spermatic cord demands attention, before the testis, 
occupying its normal position within the scrotum, is reached. 
Various affections may be found bearing the generic name 
of cele. First varicocele, a thickening of the whole sper- 
matic cord, caused by a varicose dilatation and coiling of 
the veins of the plexus pampiniformis (most frequent on 
the left side). Then comes hydrocele with its various sub- 
divisions. Congenital hydrocele is that variety in which the 
pocket of peritoneum (processus vaginalis peritonei), pro- 
duced by the descent of the testis, remains open ; the testis 
lies as a prominent body at the bottom of and within the 
pouch. Another form is hydrocele of the cord, in which the 
walls of the peritoneal pocket are united above the testis, 
and at the origin, while the portion between these two 
points is converted into a cystic enlargement, varying in 
size and position. If there are several cystic dilatations pres- 
ent, the term cystic hydrocele of the cord is used. This may 
be easily mistaken for a hydrocele herniosa, which is pro- 
duced by a collection of fluid within a hernial pouch the ori- 
fice of which is obliterated. As a rule this sac lies near 
the peritoneum, and is often surrounded by a thick, fatty 
capsule. Hydrocele tunicce vaginalis propria^ testis leads us 
directly to the testis, it being an affection characterized by 
a collection of fluid between the parietal layer of the pouch 
and the testis. The fluid is sometimes clear, watery (with 
fibrinogenous substance), at others purulent, and very fre- 
quently bloody, especially in large hydroceles. The blood 
has often undergone changes, and the contents of the sac 
then have a chocolate color and a pulp-like consistency (hce- 
matocele). Sometimes the watery fluid is cloudy, like milk, 
due to the presence of cells containing fat granules, granular 



THE TESTIS AND EPIDIDYMIS, 235 

corpuscles, or to fat drops. At the upper extremity of the 
testis, cysts, which may attain the size of a walnut, project 
into the sac and are connected with the spermatic canals, 
and consequently contain spermatozoa (spermatocele). Cysts 
may also arise from what is known as the hydatids of Mor- 
gagni. 

The walls of a true hydrocele of long standing show 
many changes of an inflammatory nature, so that there is 
no sharp line of demarcation between the two. The changes 
consist principally in a sclerotic thickening (periorchitis 
fibrosa), which is often partial and may become cartilaginous 
or calcined. At other times, growths resembling warts, pa- 
pillae, etc. (periorchitis prolifera), make their appearance ; 
these also consist of a dense fibrous tissue, and may become 
detached (free bodies), often being calcified in their centre. 

Finally other cases may present an adhesion between the 
tunica vaginalis and testis (periorchitis adhcesiva), which 
may cause a partial or even total obliteration of the sac. 
These are often of syphilitic origin. Purulent inflammation 
(periorchitis or vaginitis suppurativa) is easily recognized 
by the purulent character of the contents of the sac. It 
may be traumatic in its origin, or secondary to some other 
affection of the testis. 

2. The Exterior of the Testis and Epididymis. 

The testis, in consequence of various processes (inflamma- 
tory or the growth of tumors), may undergo a hypertrophy, 
sometimes exceeding the size of a man's fist. Atrophy is 
constant in old subjects, and also occurs as the result of an 
arrest of development after puberty, from the compression 
of hydrocele, and finally from chronic fibrous inflammation, 
especially that of syphilis. The epididymis is independent 
of the testis, with reference to changes in size. In many 
forms of inflammation, especially in those which affect sim- 
ilarly other portions of the genito-urinary organs (gonor- 
rhoea, tuberculous inflammation), the epididymis is enlarged. 
The consistency of the testis, which is very soft, becomes 



236 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

still softer and more compressible, in the atrophy of old age 
and in that arising from pressure, provided the tunica albu- 
ginea is not unusually thickened. In fibrous atrophy the 
gland is decidedly firmer, also in most inflammatory changes, 
whereas in many tumors the consistency is perfectly soft 
(medullary). 

3. The Interior of the Testis and Epididymis. 

In order to examine the parenchyma a longitudinal incis- 
ion is to be made, beginning on the side opposite the epidid- 
ymis and extending through the body of Highmore into the 
epididymis. The latter, especially its head, may also be ex- 
amined by a separate incision. 

The color of the normal parenchyma is, according to the 
amount of contained blood, gray or grayish-red. When it 
is pale yellow or yellowish-brown, and the parenchyma is 
very soft, it is an indication of fatty degeneration of the 
cells within the tubules of the testis, which appears usually 
in atrophy, especially in that of old age. A grayish- white 
color, combined with fibrous hardness, arises from the devel- 
opment of fibrous tissue. The clear yellow color of cheesy 
masses is, in the majority of cases, to be attributed to tuber- 
culosis. 

Haemorrhages, hemorrhagic infarctions {embolic), and 
embolic abscesses, occur here also, but much less frequently 
and more extensively than in other organs. 

The acute inflammations are rarely met with. As is well 
known, the epididymis is the favorite seat of purulent in- 
flammation {epididymitis apostematosa), so frequently gon- 
orrhoea!, still the testis is not always free. In the latter, 
cavities of various size are sometimes found, containing 
greasy yellow masses, composed of fat and glistening choles- 
terine crystals (atheroma of the testis), or of such petrifac- 
tions as result from former abscesses. Cicatricial bands, 
which often extend to the integument and thus produce a 
deep depression, may also be due to abscesses which have 
led to the formation of fistulae and then healed. "While the 



THE TESTIS AND EPIDIDYMIS. 237 

fistulae exist they are frequently lined with a layer of granu- 
lation tissue, which may project upon the surface like a tu- 
mor. Chronic inflammation is recognized by the fibrous 
thickening of the interlobular septa, on account of which the 
intervening glandular tissue is more or less atrophied. 

Tuberculous and syphilitic affections of the male gener- 
ative glands, are of the utmost importance. They may be 
distinguished in a general way from each other by the fact 
that the former first attacks and has its principal seat in the 
epididymis, while the latter first attacks and has its princi- 
pal seat in the testis proper. 

Among the tuberculous affections, two varieties may be 
distinguished. In the first the epididymis forms a sausage- 
like swelling, and has often undergone complete cheesy de- 
generation, while in the parenchyma of the testis there is 
no apparent change, or there are very scattered gray, miliary 
or submiliary, tubercular nodules, which diminish in num- 
ber from the corpus Highmori towards the periphery, and 
may be cheesy. In recent cases it may be easily ascer- 
tained that the process begins in the walls of the epididy- 
mis and vas deferens, for the latter, and other portions of 
the genito-urinary organs, usually share in the disease ; the 
wall is thickened, gray, and translucent, the superficial por- 
tions are infiltrated to a slight extent with cheesy material, 
and the inner surface is covered with a layer of the same. 
As a rule, the tissues are so firm that sections may be made 
with a sharp razor, and in these the presence of tubercles in 
the peripheral layers of the walls may easily be seen. The 
greatest development of the affection is, as a rule, in the 
head of the epididymis, which in cases of long duration may 
be converted into a cavity filled with a greasy, cheesy mass. 
Not unfrequently perforation takes place, a fistulous opening 
of greater or less width is then found on the scrotum, lead- 
ing directly into the interior (fistula testis tuberculosa'), from 
which a caseo-purulent secretion is discharged. In the testis 
proper the tubercles are situated in the interstitial tissue, 
which is increased and appears in the form of gray lines, radi- 



238 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

ating from the corpus Highmori, or as round gray spots. 
The tubercles may become very numerous in the testis, and 
by their confluence produce large cheesy masses, so that 
finally the testis may attain the size of a hen's egg, or even 
that of a lemon. The affection is unilateral, or bilateral ; in 
the latter case one side is often more affected than the other. 
According to Gaule the formations which have always been 
looked upon as tubercular nodules are the result of an in- 
flammation of the tissue about the tubules of the testis (peri- 
spermatophoritis'), combined with changes within them, just 
as the peribronchitic pseudo-tubercles are the product of an 
inflammation of the peribronchial tissue, except that in the 
latter case each nodule involves but one small bronchus, while 
in the former a number of tubuli are involved. 

The second variety is met with especially in boys who are 
suffering from general tuberculosis. It has its seat from the 
beginning in the testis proper, and is essentially a dissem- 
inated miliary tuberculosis, which may however produce large 
cheesy masses by the confluence of the nodules. 

The syphilitic affections of the testis vary according as 
they are manifested by a simple interstitial fibrous inflam- 
mation (orchitis interstitialis fibrosa), or the formation of 
gummata (sarcocele syphilitica). 

The former somewhat resembles in its gross appearances 
the first form of tuberculous inflammation, since the changes 
are greatest in the corpus Highmori, and disappear gradually 
towards the periphery. Firm, fibrous, cicatricial bands are 
seen, varying in width, at first connected with each other, 
but becoming more and more separated as they approach the 
surface ; they correspond to the direction of the septula tes- 
tis, in which the affection essentially runs its course. The 
fibrous bands give off numerous lateral branches, so that 
their combined appearance upon the surface of the section 
may be compared to a stag's horns. The affection is fre- 
quently only lobular, but it may extend over the whole 
parenchyma. The parenchyma lying between the fibrous 
bands naturally undergoes atrophy from compression, so that 



THE TESTIS AND EPIDIDYMIS. 239 

the testis, at least in the later stages, is always diminished 
in size. When the affection is extreme, total fibrous atro- 
phy may finally result. 

G-ummata of the testis never occur alone, but always in 
connection with an interstitial fibrous orchitis. The yellow, 
dry, tough, elastic, fatty masses of the gummata lie imbed- 
ded in the fibrous product of interstitial inflammation, and 
consequently have a much more irregular appearance than 
the first form. The gummata are sometimes in the form of 
miliary nodules ; again they form large irregular masses, which 
lead to considerable enlargement of the testis. The fatty 
masses here, as in other organs, may gradually disappear by 
absorption, so that only a fibrous cicatricial tissue remains, 
which sometimes is only to be distinguished from the fibrous 
tissue of interstitial inflammation by its unusual situation, it 
being separated from the corpus Highmori by relatively 
normal tissue. A chronic fibrous periorchitis, and frequently 
the adhesive form also, are usually combined with the syph- 
ilitic processes. 

The testis is a favorite seat for all varieties of tumors. 
These are sometimes simple ; again (and in this respect the 
peculiarity of the testis consists), they are mixed, presenting 
the most peculiar combinations. The teratoid tumors, which 
have their favorite seat in the ovaries, occur rarely in the 
testis. The most frequent forms are the mixed tumors of 
the histioid class, especially myxosarcoma ; also chondrosar- 
coma, the character of which is sometimes so apparent that 
the position of the separate parts of which it is composed 
may be determined with the unaided eye. While the dif- 
ferent tissues which form the mixed tumors are more dis- 
tinct in other organs, in many chondrosarcomata of the testis 
both tissues are intimately mixed. The cartilage appears as 
a worm-like deposit in the sarcomatous mass, easily removed, 
and evidently situated within preexisting spaces (lymph ves- 
sels), which are somewhat distended. 

Myxosarcoma and chondrosarcoma also occur here. What 
has been already said in regard to distinguishing these tu- 



240 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

mors applies to them here. In general, mixed tumors pos- 
sess a sarcomatous base. Pure sarcoma and pure carcinoma 
may often be distinguished from each other by their general 
gross appearances. (In carcinoma it is possible to scrape 
off a milky fluid ; a coarse network is often apparent to the 
naked eye, and from its interspaces the milky fluid exudes. 
Sarcoma, which has a more even surface, does not permit 
such a fluid to be pressed out.) In the most malignant 
growths, the soft encephaloid tumors, the differential diag- 
nosis can be made only with the aid of the microscope. Tu- 
mors of the testis are often remarkable for the abundance of 
vessels which they contain, and the thinness of their walls, so 
that hemorrhagic forms are of frequent occurrence. Other 
forms than those already mentioned appear exceptionally, for 
instance, myomata, osteomata, etc. Bony tumors must not 
be confounded with petrification of the testis, which is occa- 
sionally found, and has already been mentioned as the result 
of a purulent inflammation. 

(#.) THE VULVA. 

The external female genitals may be examined in the 
manner already described, either in situ or after they have 
been removed. The changes in size, due to the enlargement 
of the labia majora from oedema, and elephantiasis, have 
already been considered in treating of the skin. The labia 
minora, in women who have borne children, are often in- 
completely covered by the greater labia, and sometimes 
form long, red pendulous projections, of varying thickness. 
From one or both sides of the prepuce of the clitoris also, 
especially where it is continuous with the nyniphae, masses 
resembling pads or polypi, hang down near the orifice of the 
urethra, in front of the vaginal orifice, and even project from 
the opening between the nymphae. Occasionally the clitoris 
itself shows congenital enlargement, which is then frequently 
associated with other anomalies of formation, constituting 
what is known as hermaphroditism. 

Solution of continuity of the parts, especially a rupture of 



THE VAGINA. 241 

the frenulum, extending into the perinseum even, is almost 
always the result of childbirth. Partly superficial and partly 
deep lacerations may be found in all possible places; when 
connected with marked swelling, redness, and even purulent 
inflammation of the parts, they always suggest the suspicion 
of an attempt at rape, especially in children, where immissio 
penis is impossible, owing to the disproportion in size. A 
traumatic laceration of the tissues, without any rupture of 
the surface, occurs in the labia majora of puerperal women; 
these parts may appear much enlarged, owing to the great 
effusion of blood into their tissues (hematoma vulval). The 
consequent inflammation may cause gangrene, which readily 
extends to the pelvic cellular tissue. Purulent inflammation 
always runs its course as a virulent catarrh, with marked 
redness and swelling of the parts. 

Of the remaining inflammatory processes the diphtheritic, 
associated with puerperal lacerations, is worthy of mention. 
It may be easily recognized by the gray infiltration upon 
the base of the ulcers. These ulcers are frequently of a per- 
fectly gangrenous character, and may be recognized as such 
by their unusual grayish-black appearance, and the necrotic 
condition of their edges and base. If the puerperal lacera- 
tions are followed by no complication they are immediately 
converted into purulent ulcers, called puerperal ulcers. 

The growths upon the external genitals, known as the 
pointed and broad condylomata, and the chancre, have been 
sufficiently described, in treating of the skin. 

Of the true neoplasms, carcinoma and melanoma originate 
principally from the clitoris. Peculiar atheromatous cysts, 
containing a butter-like mass, occur in the nymphse, also 
fibromata (papilloma), etc. 

(h.) THE VAGINA. 

The vagina is to be examined by opening it longitudinally 
on the left side, and then separating it from the anterior sur- 
face of the uterus, when it may be laid open and all its parts 
be conveniently inspected. 

16 



242 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

In order to preserve the bladder in certain cases, it is well 
to separate it from the uterus, at least on the left side, 
before opening the vagina. 

1. General Appearances. 

Changes in position, not of the vagina as a whole, but of 
certain parts, are sometimes primary, and at other times 
dependent upon a change in the position of the uterus. In 
the first class are included the protrusion of the anterior wall 
of the vagina {cystocele vaginalis), or of the lower part of the 
posterior wall, caused by the rectum (rectocele vaginalis'), 
and of the upper from the sinking of the small intestine into 
Douglas's fossa {enter ocele vaginalis). To the latter class 
belong the eversion of the vagina from prolapsus uteri, and 
the displacements due to tumors of the uterus. When the 
vaginal mucous membrane projects from the vulva, its epi- 
thelium becomes so changed as to resemble the epidermis ; 
the cells collect in thick layers {pachydermia), and cause a 
whitish, at times almost milk-white appearance of the surface. 

Variations in the size and shape of the vagina are some- 
times congenital and sometimes acquired. Besides the in- 
stances above referred to, enlargement is apt to follow 
numerous confinements, or long continued catarrh; in such 
cases the surface usually becomes smoother, owing to a dimi- 
nution in the size or a disappearance of the folds. Narrow- 
ing is of more importance, sometimes affecting the whole 
vagina (in congenital hypoplasia of the genitals, and in her- 
maphroditism), or certain portions of it. The latter deform- 
ity is either congenital (atresia) or acquired (by the contrac- 
tion of cicatrices) . The narrowing from scars is seldom total, 
and can be recognized by the cicatricial changes in the con- 
tracted portion and in its neighborhood. Small projections 
in the middle of the anterior or posterior wall are also con- 
genital, and indicate the manner of the formation of the va- 
gina by the coalescence of the two Miiller's ducts. A greater 
degree of this arrest of development is reached when a mem- 
branous septum divides the vagina into two portions ; this is 



THE VAGINA. 243 

limited either to the upper portion or extends to the entrance. 
It may occur with or without a double uterine cavity. 

The color of the vaginal mucous membrane is generally a 
light or dark reddish-gray ; decomposition causes it to assume 
rapidly a dirty gray hue, especially when a gangrenous or 
diphtheritic process is present in the vagina or in the uterus. 
The white color in pachydermia has already been referred 
to. A uniform gray color combined with fibrous induration 
is found when leucorrhoea has existed for a long time ; a 
slaty color arises from hemorrhagic inflammation. 

2. Special Morbid Conditions. 

Non-puerperal inflammation of the vaginal mucous mem- 
brane is often met with. A purulent or gangrenous inflam- 
mation with a very offensive discolored secretion, is less 
common than the chronic form, which is to be recognized 
by the gray, smooth, and indurated mucous membrane (kolp- 
tis chronica fibrosa'). The vagina, like the external geni- 
tals, often suffers much in childbirth, especially when it is 
necessary to aid labor by instruments {puerperal affections). 
When the pelvis is narrow, or the head abnormally large, 
and the forceps are applied, the blades very commonly pro- 
duce lacerations, which sometimes heal readily and cicatrize, 
and at other times become infective ulcers. This subject 
will be again referred to directly. Cicatrices situated on 
the lateral walls of the vagina and running longitudinally, 
justify the diagnosis of a difficult labor. Lacerations and 
cicatrices occur in a like way at the vault of the vagina, 
and extend outwards from the os uteri, being frequently 
connected with similar ones in the uterus ; they are also 
found at the entrance of the vagina, where they are con- 
nected with others on the external genitals. 

If the force used was very great, and especially such as to 
cause extensive crushing, a simple ulcer does not result, but 
the tissues necrose, and an offensive, greenish-black loss of 
substance with a ragged base results on both sides. In par- 
ticularly bad cases the whole thickness of the vaginal walls 



244 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

may be involved, so that perforation results, and an exten- 
sive gangrenous phlegmon of the pelvic cellular tissue fol- 
lows, which may extend to the abdominal walls. In other 
cases the trouble is situated either on the anterior or the 
posterior wall, and its location is to be explained by the pe- 
culiarities of the bony pelvis (spinous pelvis), or by irreg- 
ularities in the birth (strong pressure of the head against 
the symphysis). 

Although these lesions usually heal without further trouble 
when the necrosis does not extend too deep, they are liable 
to result in very painful fistulse, not so much in consequence 
of direct lacerations, but as a rule through subsequent ne- 
crosis. The most common form is that between the bladder 
and vagina (fistula vesico- vaginalis') ; less common are those 
between the vagina and rectum (fistula recto-vaginalis) ; 
while those between the bladder, vagina, and rectum (fis- 
tula vesico-recto-vaginalis), are the most rare. 

When the traumatic injury is followed by no deep-seated 
necrosis, a very serious affection frequently follows, arising 
from an infection of the wounded surface. Dijihtkeritis, i. e., 
diphtheritic ulcers of the vagina, is characterized by a gray 
or grayish-yellow infiltration of the wounded surface, which 
can neither be removed by a stream of water nor by scraping 
with a knife. The diphtheritic affection does not remain 
confined to the wounds, but extends over the contiguous sur- 
face also, and appears by preference upon the folds of the 
anterior and posterior walls. At the commencement of the 
affection, these folds and the neighboring portions appear 
dark red, even hemorrhagic, and their ridges are of a gray- 
ish tinge. In the same place, also, the first and most in- 
tense diphtheritic change occurs in all cases where the diph- 
theritis is not an accompaniment of the puerperal state, but 
supervenes in typhoid fever, variola, etc. 

Connected with the sexual life of the female though not 
with childbirth are syphilitic ulcers, seldom observed as such 
in the cadaver, but more frequently in the form of their 
after-effects, viz., firm, strongly contracted, radiating cica- 



THE VAGINA. 245 

trices, which of course cannot always be distinguished with 
certainty from those of puerperal origin. It is known that 
syphilitic ulcers may also lead to perforation, especially into 
the rectum, forming recto-vaginal fistula (fistula recto-vagi- 
nalis). 

Tuberculous and carcinomatous ulcers of the vagina are 
much more rare. Tuberculous affections of the female geni- 
tals are, in general, rare, and tuberculous ulcers of the vagina 
are especially so, and never occur alone, but only in connec- 
tion with tuberculosis of the uterine mucous membrane. 
Their most frequent appearance is that of shallow lenticular 
ulcers with sharp borders, as though punched out, and a 
slightly uneven bed. Sometimes they become confluent, and 
in this way large portions (of the vault and upper half of 
the vagina) may be deprived of their mucous membrane. 

Carcinomatous ulcers are much more frequent, but only 
when secondary to cancer of the cervix uteri ; the primary 
forms are rare. The term carcinomatous ulcer is used be- 
cause large, circumscribed, cancerous tumors do not occur 
here ; all cancers of the vagina observed after death have an 
ulcerated surface. In treating of the primary tumors, this 
subject will be referred to, and we will only mention here, 
that these ulcers may produce an extensive destruction of 
the vaginal walls, with an extremely penetrating odor due 
to decomposition of the secretion and to gangrene of the 
ulcerated surface. This odor may result without perforation 
of the walls and the consequent formation of a vesicovagi- 
nal fistula, which not unfrequently happens. The surface 
of the ulcer is discolored, ragged, and disintegrated, and 
there is but little of the carcinoma to be seen ; the ed^res of 
the ulcer often project above the normal vagina like a wall, 
and on cutting through them and the base, the growth will 
be seen as a tough, grayish-white mass, from which cancer 
juice or the plugs resembling comedones may be pressed. 
Perforation of these ulcers into the rectum is rare, still it 
does happen. 

There are thus a great number of processes which lead to 



246 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the formation of fistulae between the vagina and bladder, 
also between the vagina and rectum. Congenital fistulae, so 
called cloaca?, also occur. It will not be difficult, after what 
has already been said, to discover the cause of the trouble 
in each separate case. 

(z.) THE UTERUS. 
1. External Examination. 

Previous to opening the uterus certain general conditions 
are to be noted, such as the size, form, and length. The 
length of the fully developed virgin uterus, according to 
Huschke, is five and one half to eight centimeters ; the 
breadth, three and one half to four centimeters ; the thick- 
ness, two to two and one half centimeters. After childbirth 
it remains permanently enlarged, and in multipara it meas- 
ures nine to nine and one half centimeters in length ; five 
and one half to six centimeters in breadth, and three to 
three and one half centimeters in thickness. Diminution in 
size, except when the result of senile atrophy, is rare. It is 
constantly associated with fibrous degeneration of the walls, 
and usually of the mucous membrane. It is very frequently 
connected with old adhesive peritonitis, so that the uterus is 
very often completely imbedded in a firm pseudo-membrane. 

Enlargements vary greatly in degree. Aside from those 
forms which are produced by tumors upon the exterior, the 
uterus itself may attain the size of a child's head, or even 
exceed it (hydro- and pyometra, etc., intraparietal and sub- 
mucous fibromata, etc.). Enlargement is not always a sym- 
metrical one of the body and neck, but sometimes one and 
sometimes the other is the more enlarged. Hypertrophy of 
the lips of the os is at times especially marked ; both or only 
one, more particularly the anterior lip, may be enlarged. 

Variations in shape are seldom found in a uterus which 
occupies its normal position, but usually in one which is ab- 
normal in this respect. To the first class belongs the congen- 
ital bicornous uterus (uterus bicornis), which is sometimes 
merely suggested by a longitudinal furrow in the middle of 



THE UTERUS. 2-17 

the fundus, while at other times a complete separation of the 
two horns exists. The rounded form in hydro-, pyometra, 
etc., also belongs here. The changes in shape which are con- 
nected with a change in position are of the utmost import- 
ance. An elongated and flattened uterus is produced by 
many subserous tumors, and by adhesions of the uterus to 
some of the abdominal viscera which are situated high up. 
In such cases the vagina is almost always elongated. 

What are termed the flexions and versions of the uterus 
are of a somewhat different nature. The uterus may un- 
dergo a change in position without any change in the relative 
position of its parts, so that the long axis becomes more or 
less horizontal, and according as the fundus is tipped forwards 
or backwards, it is designated ante- or retroversion. Most 
frequently the position of the cervix and body relative to 
that of the fundus is changed, so that their axes do not 
coincide but form more or less of an angle (a right or even 
an acute angle), and the uterus is bent abruptly upon itself 
near the internal os (ante- and retroflexion). If the uterus 
is pushed over to one side it is termed lateroversion or late- 
roflexion. When such changes of position exist, the cause 
must be sought for, and, aside from the cases where tumors 
have developed in the walls of the uterus, will be found at 
times in a chronic inflammation of the cellular tissue im- 
mediately surrounding the uterus, and of the broad liga- 
ments (parametritis chronica fibrosa retrahens), or of the 
serous coat of the uterus (perimetritis chronica adhesiva) ; 
or finally in certain congenital irregularities in its supports 
(insufficient length of one broad ligament, etc.). 

In the first series the direct traction of the adhesions, due 
to a shrinking of the inflammatory material, draws the ute- 
rus out of its position ; in the last the immediate causes vary, 
the most important being those affecting the intra-abdom- 
inal pressure (pressure from intestines, etc.), which, how- 
ever, can only act when combined with the more remote 
cause, the congenital deformity. As the neck of the uterus 
is firmly attached to the posterior wall of the bladder, the 



248 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

force which displaces the uterus will first take effect at the 
point where this attachment ceases, and this corresponds to 
the internal os, where the flexion is always situated. After 
a while the nutrition of the wall, at the point where the angle 
is formed, naturally becomes seriously disturbed ; atrophy 
takes place, and the muscular elements become fatty, but 
these changes are the effect of the flexion and not the cause. 
The common anteflexion of the puerperal uterus is due to 
flaccidity of the tissue. 

The change in position, called prolapsus uteri, depends 
upon too lax a condition of the uterine ligaments and the 
tissues of the vagina, such as exists especially after child- 
birth. The uterus, without changing its shape, sinks into 
the vagina, and the latter is more and more everted till the 
external os finally projects from the vulva. On the other 
hand the change in the vagina (cystocele or rectocele) may 
be primary, the effect of which is to draw down the uterus. 
A considerable hypertrophy, usually most marked at the 
neck, is always combined with prolapse. The cervical en- 
largement may be primary and so extreme that the external 
os reaches down to the entrance of the vagina without the 
body of the uterus being drawn down in the least. It is 
not difficult to recognize this apparent prolapsus, when the 
position of the fundus is noted, and also the absence of pock- 
ets, which are produced on the anterior and posterior surfaces 
of the uterus in true prolapse. The abnormally projecting 
portion is often of a whitish color and covered with a firm, 
tough, epidermis-like layer, the same pachydermia which 
has been referred to in speaking of prolapse of the vagina. 
Ulcers, also, especially about the os, are very frequently 
associated. 

Finally, inversio uteri must be mentioned. By this is un- 
derstood a condition in which the uterus is so inverted that 
the fundus enters the neck, and consequently the mucous 
membrane of the former is turned outwards. This condi- 
tion is the result of external force upon the puerperal uterus 
(traction upon the cord, etc.), or less frequently of tumors 
(submucous polypi). 



THE UTERUS. 249 



2. Internal Examination. 



All the changes which have thus far been considered, are 
best observed upon the unopened organ. For a more ex- 
tended examination the uterus is to be opened by a T 
shaped incision, the long arm of which is made through the 
middle of the anterior wall, and the two shorter ones extend 
from its middle to the point where the Fallopian tubes are 
given off. 

(a.~) General Characteristics. 

The thickness of the walls is first to be noted. This in no 
way corresponds to the size of the organ ; for instance, in hy- 
drometra, it may be from one to two millimeters thick only, 
and on the other hand, it sometimes reaches three centime- 
ters (when not impregnated). The average thickness is ten 
to fifteen millimeters in the virgin, and twenty millimeters 
in the uterus of the adult. 

The relative size of the body and neck is of the utmost 
importance in judging of the previous condition of the 
uterus. In the normal virgin uterus the length of the body 
and neck are about equal (in childhood the cervix is larger 
than the body), so that a diminution in the size of the neck 
with an opposite condition of the body, points to previous 
pregnancy ; this is rendered more probable by the absence 
of the spindle form of the virgin neck. For the same reason 
the condition of the uterine walls, their thickness, and the 
relation of their component parts, is important. In the ab- 
sence of other local affections, a large, thick uterus indicates 
a previous pregnant condition ; the same inference is to be 
drawn from the presence of wide, thick- walled vessels, espe- 
cially in the outer portion of the uterine walls, as after hav- 
ing become enlarged in pregnancy, they never resume their 
normal size. If the well-known changes in the vaginal por- 
tion of the cervix be also taken into consideration, there will 
be points enough to make the diagnosis of previous preg- 
nancy with tolerable accuracy. These changes consist in a 
conversion of the external os, which is normally a transverse, 



250 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

oval, smooth-edged slit, into an irregular round opening with 
a border notched by cicatrized lacerations. 

There is a group of changes, namely, enlargements of the 
uterine cavity, which may depend upon all possible affections, 
but which have for their immediate cause an obstruction 
of the cervical canal. When this exists, there is a retention 
of fluid in the uterine cavity, and by its constant increase 
the cavity, likewise the whole uterus, becomes distended and, 
as other organs under similar circumstances, tends to assume 
the spherical form, and may finally become almost globular. 
According as the contents are a clear watery, purulent, or 
bloody fluid, the condition is designated as hydro-, pyo-, or 
hoematometra. If gas is also present (from decomposition of 
pus, etc.), it is termed physometra. The cause of the ob- 
struction is varied. The ordinary hydrometra in old women 
is due to closure of the internal os from chronic endometritis. 
The retained fluid is always watery, while in dilatation of 
the cervix, which also occurs, the contained mass is a tena- 
cious mucus. Sometimes the obstruction is due to a tumor, 
which either directly, or through the bulging of the walls, 
narrows or closes the cavity ; at other times it is due to a 
cicatrix, and a complete closure may be thus caused, as the 
result of ulcers, or of congenital disturbances. 

After the color of the walls and their consistency also 
have been observed, the mucous membrane is to be exam- 
ined in respect to its thickness, color, and consistency. The 
walls are usually reddish-gray, in fatty degeneration clear 
yellow, brittle, and easily cut ; in chronic fibrous inflamma- 
tion they are of a uniform grayish-white color, very tough, 
and impart a grating sensation when cut. The mucous mem- 
brane is increased in thickness in acute, and chronic prolif- 
erating inflammation, decreased in the chronic fibrous form. 
Its color, normally gray, or grayish-red, becomes dark-red in 
hemorrhagic inflammation, slaty in the chronic hemorrhagic 
variety, and grayish-white in chronic fibrous inflammation, 
etc. The consistency is soft when the mucous membrane is 
swollen, hard and fibrous in chronic fibrous inflammation. 



THE UTERUS. 251 

The recognition of the menstrual or puerperal condition of 
the uterus is especially important. During menstruation, 
the uterus is enlarged (to the size of a hen's egg)-, its sub- 
stance soft and juicy ; the mucous membrane is swollen, suc- 
culent, reddened from the engorgement of the blood-vessels, 
and covered with a more or less pure or watery blood, ac- 
cording to the duration. Menstrual blood coagulates with 
difficulty, but it is by no means devoid of that property. 
The puerperal uterus will, of course, present a very different 
aspect, according to the time which has elapsed since con- 
finement, and according as the pregnancy had continued to 
its full term, or was cut short (abortion). The signs easily 
recognized soon after confinement, are the size of the uterus 
(from that of the fist to that of a goose-egg), the seat of the 
placenta, characterized by the warty growths, and the lacera- 
tions in the external os, in connection with the presence of 
large, wide vessels in the walls. Later these gradually dis- 
appear, the seat of the placenta differs but little from the 
surrounding surface, the lacerations heal, and the puerperal 
uterus resembles the ordinary menstrual organ. In order 
to distinguish the two, the examination of the ovaries will 
be of service ; in the former case a small, old corpus luteum 
will be found, in the latter a recent, very large hsemorrhagic 
one. An important point in the diagnosis of a recent labor 
at full term, or of a premature labor, is an orange discolor- 
ation of the mucous membrane of the neck of the uterus, 
which is often present. The width of the internal os is also 
important; this becomes narrow in the process of involution, 
and in chronic inflammation, in the latter abnormally nar- 
row as a rule. 

(5.) Special Morbid Conditions. 

The puerperal uterus is subject to a very great number of 
affections, and they are of especial interest to the pathologist, 
as they are so frequently the cause of death, while the in- 
flammatory affections of the non-puerperal uterus are only 
occasionally found, the acute forms being very rare. 



252 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

1. Mechanical lacerations, are the simplest injuries to the 
uterus from the effects of childbirth ; they have already been 
spoken of as occurring at the neck, and especially in the 
external os, and often reach into the vagina. Among the 
rarest accidents is rupture of the body of the uterus or of 
the neck. The rent is usually in the body, and the ovum, 
entire or in part, may pass through it. Recovery from so 
extensive an injury is exceedingly rare, but the preexistence 
of the less severe forms is indicated, as has already been 
mentioned, by the frequent presence of scars. 

Closely connected with the simple lacerations are those 
affections which, when extreme, were formerly called putres- 
centia uteri, and which have already been spoken of in con- 
nection with the vagina. The surface of the wounds, the 
neighboring parts, and often the whole inner surface of the 
uterus, is found converted into a pulpy, stinking, grayish- 
green, and sometimes, when haemorrhage has occurred, 
brownish mass, extending more or less deeply. This con- 
dition is one of true gangrene (gangrama uteri, endometritis 
gangrenosa, ichorosa). The destruction of the tissue, as in 
the vagina, may vary in depth, and a complete necrosis of 
the walls with perforation, is liable to occur, especially in 
the cervical portion, where the mechanical injury is great- 
est. The perforation is followed by the results already 
mentioned, only here the peritoneum may become involved, 
owing to its proximity. 

2. The inflammatory changes depend less directly upon 
the mechanical injuries than upon a resulting infection ; 
they may be confined to the mucous membrane, to the mus- 
cular tissue, or they may affect both. In the first case they 
are manifested by a diphtheritic inflammation {endometritis 
diphtheritica), which is ^indistinguishable from that of other 
mucous membranes. It presents the same gray, grayish- 
yellow, or grayish-white color upon the surface, from which 
thick gray masses may frequently be removed. There is 
also an infiltration of the mucous membrane itself, which 
may be best seen by cutting perpendicularly into the walls. 



THE UTERUS. 253 

The liability of confounding these appearances with rem- 
nants of the decidua is thus prevented. The latter also usu- 
ally possess a grayish-yellow color, but lie loosely upon the 
surface, so that they may be easily removed, frequently by 
means of a stream of water only. They consist of decidual 
tissue, which has undergone fatty degeneration, while the 
diphtheritic masses, when examined microscopically, present 
colonies of micrococci, as seen in other mucous membranes. 

The locality and extent of the diphtheritic affection, both 
in area and depth, are very variable. It usually takes its 
origin in the lacerations of the cervical portion, or in the 
place where the placenta was attached, both of which afford 
particularly favorable conditions for infection. Not infre- 
quently the diphtheritis remains confined to the place of the 
placental attachment, and the mucous membrane of the re- 
maining portion becomes simply inflamed, swollen, and in- 
tensely reddened. Sometimes, while the surface of the pla- 
cental insertion is diphtheritic, the opposite wall presents the 
very commencement of a similar infiltration. Such a con- 
dition is important as throwing light upon the method of 
extension of this form of inflammation. The infiltration in 
the uterus, as in the vagina, first appears upon the most 
prominent places, and this is usually most marked at the 
place of placental attachment, a condition which may be 
considered as direct evidence of infection from an external 
source. 

The changes within the uterine walls vary according as 
they affect the blood-vessels, lymphatics, or the parenchyma. 
In order to learn the condition of the blood-vessels, perpen- 
dicular incisions must be made, especially through the place 
of placental attachment, for here they are largest and most 
numerous, and some are always found open after confine- 
ment. These are closed by thrombi in the physiological 
involution of the uterus. 

A more or less firm blood clot is sometimes seen on the 
seat of the placenta (rarely after normal labor, more fre- 
quently after abortion), varying in size from that of a plum 



254 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

to that of a walnut, or even larger, which projects into the 
uterine cavity, at times filling it (fibrinous, placental poly- 
pus, hcematoma polyposum, Virchow). Remnants of the 
placenta, besides the blood, are frequently found within this. 
Soft, crumbly, yellowish-red thrombi frequently appear in 
the vessels of the placental attachment instead of normal, 
firm clots, and are surrounded by a thickened yellow wall 
(thrombophlebitis placentaris). Such a thrombophlebitis may 
also take its origin at other points, especially in the cervical 
lacerations, so that longitudinal incisions are always to be 
made here. The blood-vessels within the outer layers of 
the uterine walls are found empty when normal, but the 
thrombophlebitic process frequently extends into them, when 
it is possible to press from their interior a dirty brown or 
yellowish-red mass. 

Similar affections of the lymphatics are quite as frequent 
if not more so, and appear with or without changes in the 
veins. As blood is not their natural contents they are filled 
with a clear yellow, puriform mass, and are characterized 
by the thinness of their walls, so that their nature may be 
diagnosticated from this property alone, independent of the 
fact that the contiguous blood-vessels may always be recog- 
nized as such. Their walls are also frequently inflamed, 
which condition is indicated by the yellow color resulting 
from purulent infiltration. A dilatation, which occurs with 
the described changes in the blood-vessels, is usually very 
marked in the lymphatics, so that they may form cavities 
as large as a cherry. Their contents are especially well 
suited for the recognition of micrococci. In many cases 
the whole mass filling them consists solely of these little 
bodies. 

The third variety of inflammation is that of the parenchy- 
ma, metritis phlegmonosa or apostematosa. It is character- 
ized by the occurrence of numerous circumscribed collections 
of pus of varying size, which may be distinguished from sec- 
tions of lymphatics by their not being bounded by a smooth 
wall. All forms of inflammation of the uterine parenchyma 



THE UTERUS. 255 

very frequently occur, combined with similar changes in the 
pelvic cellular tissue (parametrium). The latter and inflam- 
mation of the serous covering (perimetritis) will be described 
hereafter. 

Total fatty degeneration of the uterine walls can only 
be considered in connection with the above affections, on ac- 
count of its being due to the puerperal state. It originates 
after confinement, and is usually due to general marasmus, 
in which condition the normal fatty degeneration of the 
muscular wall becomes excessive, and is not compensated for 
by a new growth of muscular cells. Such a fatty degenerated 
uterus may often be somewhat enlarged, and is more or less 
yellow, and remarkably soft, so that when cut into it often 
resembles butter. The mucous membrane may present a sim- 
ilar change. 

Acute inflammatory affections of the non-puerperal uterus 
are seldom found at the autopsy. This applies especially 
to the purulent forms of severe endometritis, which may 
moreover be easily diagnosticated. Phlegmonous inflamma- 
tion within the muscular tissue occurs only very exception- 
ally as an independent affection. 

Catarrhal endometritis is more frequently met with. It 
is characterized especially by the quantity of tenacious, 
glossy mucus, which not only covers the mucous membrane 
of the actual uterine cavity, but also frequently fills the 
cervical canal. 

Endometritis hemorrhagica may be defined as a condi- 
tion of the mucous membrane, in which it is rendered dark 
red, not only by great engorgement of the blood-vessels, but 
also by numerous small haemorrhages. The resemblance to 
the menstrual condition may be very great, but an examina- 
tion of the ovaries will serve to distinguish the two condi- 
tions. 

Finally, an endometritis fibrinosa also occurs, in which a 
complete cast similar to that occurring in dysmenorrhea 
may be formed. The latter possesses a rough, papillary 
outer surface, and often occurs in the form of a sac, which 



256 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

may be cut open, while the former always possesses a per- 
fectly smooth surface, and is frequently solid. The differ- 
ential diagnosis is very easily made with the microscope. 

Chronic forms of inflammation, of the mucous membrane 
and of the muscular tissue, are much more frequently met 
with than the acute forms. Here, as in all mucous mem- 
branes, the term chronic inflammation is not perfectly cor- 
rect, because the conditions found relate more to the effects 
of inflammation than to the process itself. Such are the 
slaty color of the mucous membrane, due to previous small 
haemorrhages ; also the frequent fibrous induration by which 
the whole membrane is converted into a smooth, firm mass, 
cut with difficulty, and found, upon microscopic examination, 
to be devoid of glandular elements {endometritis chronica 
fibrosa). Finally, there are the little cysts which almost 
always occur in large numbers, especially in the cervical 
portion, and which vary from the size of a millet-grain to 
that of a split pea, and contain a clear watery or colloid 
material. These are known as the Nabothian glands (ovula 
Nabothi). They are retention cysts, produced by compres- 
sion of the mouths of the glands, as is proven by the presence 
of ciliated epithelium upon their walls. 

A second form of chronic endometritis is accompanied by 
hyperplasia of the mucous membrane, appearing first in 
the form of little protuberances which later resemble warts, 
and finally polypi {endometritis prolifera, polyposa). These 
growths are not confined to single layers of the mucous 
membrane, but involve the whole thickness, so that the 
glands also become enlarged ; the ducts of the latter may 
finally be closed, thus a retention of the secretion and cystic 
enlargement result, under which conditions the polypi may 
consist wholly of cysts (polypus hydatidosus~). These polypi 
are usually seated in the cervix, while the molluscum form 
(small growths situated upon a wide base) occurs in the 
body of the uterus. 

Chronic inflammation of the muscular tissue (metritis 
chronica) is characterized by a whitish-gray color and ex- 



THE UTERUS. 257 

treme hardness, so that the wall is frequently cat with diffi- 
culty and grates when cut. An enlargement of the organ 
(formerly called chronic uterine infarction) accompanies 
the fibrous degeneration, but may later become extremely 
atrophied, by the complete destruction of the muscular ele- 
ments and a retraction of the fibrous tissue. Hypertrophy 
does not always affect all the parts uniformly, the neck be- 
ing more frequently enlarged than the body. Very fre- 
quently the uterine cavity presents a peculiar hour-glass 
form, the lower part of the cervix being dilated like a fun- 
nel. Chronic endometritis is a constant associate of chronic 
metritis. 

While considering the subject of inflammation, an affection 
which frequently occurs on the portio vaginalis of the neck 
is to be mentioned, namely, the shallow, round, and fre- 
quently confluent erosions, which have a reddened base, and 
are commonly known as catarrhal ulcers of the external os. 
Occasionally purulent cysts, varying from the size of a pin's 
head to that of a millet-grain, occur in the immediate neigh- 
borhood of the ulcers, imbedded in the tissue. These origi- 
nate in part from the suppuration of the Nabothian glands, 
and in part from the inflammation of glands, the mouths of 
which have subsequently become closed. By their rupture 
the so-called follicular ulcers are produced. When the above 
changes are combined with general or partial hyperplasia of 
the mucous membrane, an acne-like formation results, so that 
the cervix bears a very great resemblance to a " Burgundy 
nose" (Virchow). 

3. The changes produced in the uterus by tuberculosis 
serve as a connecting link to the tumors proper. Tuber- 
culosis of the uterus is rare, being much less frequent than 
in the male generative organs. It occurs as a disseminated, 
pure, so-called miliary tuberculosis, and in the form of cheesy 
degeneration, which might be termed phthisis uterina. Both 
forms have their seat, i. e., point of origin, in the mucous 
membrane ; the former, however, remains confined to it, 
while the latter extends to a greater or less depth into the 

17 



258 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

uterine parenchyma. The diagnosis of the first and rarer 
form is easily made by the presence of small, translucent, 
gray, submiliary nodules, which form little prominences upon 
the surface ; that of the second is equally easy, the surface of 
the mucous membrane being converted into a crumbly, yel- 
low, cheesy mass, of greater or less depth, from the freshest 
portions of which it is possible to isolate small yellow or gray 
nodules. If it were possible for the cheesy material to be 
carried away, as in the kidney, for instance, a cavity, t. e., 
ulcerative enlargement of the uterine cavity, would result 
here ; but the whole mass remains in the place where it is 
formed, and, as it constantly increases, the interior of the 
uterus finally becomes completely filled. Horizontal sections, 
made through the diseased uterine wall with a double knife, 
show the nodules plainly at the outer edge of the cheesy 
mass. 

Carcinoma, next in order after tuberculosis, belongs to the 
tumors proper. This rarely takes its origin in the body of 
the uterus, but very frequently in the cervical portion, and 
especially at the external os. It occurs in two essentially 
different forms. The first is rare, and occurs in the form of 
an actual tumor originating from the external os, and when 
extensive involves the whole vaginal portion of the cervix, 
completely filling the upper portion of the vagina. The 
tumor does not present a compact mass with a smooth sur- 
face, but is composed of separate papillae, which are situated 
so near together that they resemble a cauliflower, hence the 
name cauliflower excrescence has been applied to it. As it 
extends, the vagina and also the body of the uterus may 
become involved, their walls thickened, and the well-known 
masses of cancer cells, cancer bodies, may be pressed from 
their cut surface. These are found, upon microscopic exami- 
nation, to be composed of clumps of large, flat, horny, epi- 
thelial cells, arranged concentrically. The presence of these 
is evidence that the growth is a cancroid. 

Upon the surface of the cauliflower growth an ichorous 
disintegration of the tissue is very liable to occur, so that it 



THE UTERUS. 259 

is converted into a stinking, dirty greenish-gray mass of 
shreds which float in water. 

This condition occurs still more frequently in the second 
form, which differs from the first in the complete absence of 
the appearance of any tumor, and in its resemblance to an 
ulcer. The process may be compared in this respect to the 
well-known rodent ulcer of the nose, and it possesses the 
eroding quality also in an extreme degree. This may termi- 
nate in a complete destruction of the portio vaginalis, the 
whole cervix, a large portion of the vagina, and finally of 
the uterine body itself. Perforations into the bladder, rec- 
tum, and even into the abdominal cavity, are relatively fre- 
quent. On account of the common gangrenous character of 
these ulcers their presence is most offensive. In order to 
make sure of their nature, it is necessary to make incisions 
in all possible directions through their edges and base, when 
the still intact new formation will be brought to view. 
Moreover, the presence of parametric, or sacral lymphatic 
glands, which have undergone carcinomatous degeneration, 
is usually sufficient to decide the nature of the affection. 

Primary carcinoma of the body of the uterus, which is 
rare, produces a thickening of the walls, and like the secon- 
dary forms is usually quite extensive. Upon section, it has 
the appearance of a grayish network, from the meshes of 
which white or yellowish-white cancer juice may be pressed 
out. The surface of the uterine cavity may be perfectly 
intact (not ulcerated). The form of the cells of this can- 
cer, which is usually soft, is often cylindrical, thus indicat- 
ing their origin distinctly (from the utricular glands). The 
common fibroid is the most important of the remaining tu- 
mors, as it is by far the most common ; it is of very frequent 
occurrence, especially in old subjects. Virchow has shown 
i that these tumors are not pure fibromata, but rather fibro- 
myomata or myomata, and that they are to be considered as 
a hyperplasia of the elements in the uterine walls. The con- 
sistency is softer or harder, according as the fibrous tissue 
or the smooth muscular cells preponderate, the color upon 



260 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

section being reddish in the former case, in the latter whitish. 
The cut surface has a striated appearance due to an inter- 
twining of the bundles of muscle, or of fibrous tissue. The 
striae become more apparent when there are white fibrous 
bundles present by the side of the more reddish muscular 
tissue. In the small tumors, and in the pure myomata, a 
simple system of bundles is present ; while the larger ones, 
especially the fibroids, possess several systems, so that they 
appear to be composed of a number of lobes. 

The size of these tumors varies from that of a pea to that 
of a man's head. Their favorite seat is in the body of the 
uterus, more particularly in the fundus and posterior wall, 
which is normally somewhat thicker than the anterior. Ac- 
cording to their situation in the walls, they are termed sub- 
serous, submucous, or intraparietal. It is perfectly evident 
that the intraparietal forms may easily become subserous or 
submucous, by increasing in size ; still tumors of the size of 
a man's head occur, surrounded on all sides by the uterine 
walls. Of course this is only possible when there is an 
enormous general hyperplasia of the walls. The soft varie- 
ties are not sharply defined, but the hard fibrous forms often 
project from the surrounding surface, when cut through. 
The subserous tumors are usually multiple, and may attain 
a very considerable size. It is often difficult to make out 
the connection of the larger ones with the uterine muscular 
tissue, although they have originated from it, as the pedicle 
is liable to atrophy, and consequently the tumor appears to 
be separated from the uterine walls, and to simply lie near 
them. The submucous growths do not generally attain the 
enormous size of the above mentioned forms, and belong 
rather to the softer variety. They hang polypus-like, often 
by an extremely delicate pedicle, in the correspondingly en- 
larged uterine cavity. As they are always covered with 
mucous membrane, they are liable to be confounded with 
mucous polypi, from which they are to be distinguished by 
their greater hardness, the striated appearance of their cut 
surface, and the absence of cysts. These tumors are fre- 



THE UTERUS. 261 

quently accompanied by a soft swelling of the uterine walls, 
with hyperplasia of the muscular bundles, a condition re- 
sembling that of the pregnant uterus. It is possible for a 
large myomatous polypus to produce an inversion of the ute- 
rus. The subserous tumors may cause versions, flexions, and 
other displacements of the uterus. Fresh sections are easily 
made, and show, on microscopic examination, interlacing 
fibrous and muscular bands, the elements of the latter with 
their rod-like nuclei being very apparent, especially after 
the addition of acetic acid ; sections colored with aniline 
violet and hasmatoxyline make very pretty preparations. 
The contractile cells may be isolated by the usual reagents 
(twenty per cent, strength of nitric acid, or a thirty-three 
per cent, solution of caustic potash). 

The uterine myomata may undergo many secondary 
changes, some of which are of a progressive and others of a 
retrogressive nature. The former consist in a partial or com- 
plete purulent inflammation ; the latter in fatty degeneration 
combined with softening, in partial mucous degeneration 
(cyst formation) ; or in calcareous infiltration (petrifaction), 
which occurs especially in the subserous and intraparietal 
varieties. The whole tumor may be converted into an un- 
even mass of stony hardness, in which, however, the smooth 
muscular cells may be brought out by treatment with hy- 
drochloric acid. 

A peculiar variety of intraparietal myoma is the telangiec- 
tatic or cavernous fibroma, which, as its name implies, is char- 
acterized by the great size and large number of its blood 
spaces. These may constitute the greater part of the tumor, 
and at times contain thrombi. Other varieties are produced 
by the union of other new formations with the muscular tis- 
sue, as, for instance, the myxomyoma and myosarcoma. Other 
tumors of the uterus, for example, sarcoma, which Virchow 
mentions only as u infiltrated " sarcoma of the mucous mem- 
brane, and gummata, are very rare. 

4. The congenital malformations include, besides the per- 
sistence of the infantile condition (uterus infantilis), and 



262 ' DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

those deformities which occur in hermaphroditism, the dupli- 
cative caused by an arrest of development, which is some- 
times complete (uterus duplex), and again only partial, so 
that the cavity which is single below, becomes divided into 
two horns higher up (uterus bicornis). These malforma- 
tions, as has been already stated, may be apparent upon the 
outer surface of the organ, not in all cases, however, but 
only in those where the uterine cavity is divided by a lon- 
gitudinal septum (uterus septus, bicameratus). 

(&.) THE PARAMETRIUM AND BROAD LIGAMENTS. 

The examination of the pelvic cellular tissue (parame- 
trium) and broad ligaments is best made after that of the 
uterus. Their affections stand in very close relation to those 
of the uterus, as they often appear to simply extend from it, 
and on the other hand changes in the ligaments may affect 
the uterus. The most important of the latter is an inequal- 
ity in the length of the broad ligaments, which causes lateral 
flexion or version of the uterus, and may either be congeni- 
tal, or caused by the contraction which follows chronic in- 
flammation. The processes which extend from the uterus 
are essentially puerperal affections, which, when they run 
an acute course, may occur, as in the uterine walls, in three 
forms, thrombophlebitis, lymphangitis, and phlegmonous, i.e., 
purulent inflammation. Thrombophlebitis may be followed 
directly into the uterus, or it may first be met with at a little 
distance from, and apparently disconnected with, that organ. 
It is characterized by a thickening, and a yellow or green- 
ish-yellow color of the walls of the vessels, by an increase 
of calibre, and the filling of their cavity with a more or less 
reddish-brown puriform material. Its favorite seat is the 
large veins which run along by the side of the Fallopian 
tubes and empty directly into the vena spermatica, into 
which the thrombosis and phlebitis may also extend (fre- 
quently to the point where it empties into the vena cava, or 
left renal vein). 

Lymphangitis is to be recognized by the presence of puri- 



THE PELVIC CELLULAR TISSUE. 263 

form masses (lymph thrombi containing numerous granules) 
within thin-walled, dilated, varicose vessels. Phlegmonous 
parametritis often results quickly in abscesses situated within 
the connective tissue about the uterus, sometimes, however, 
it consists only in an oedematous swelling and gelatinous in- 
filtration of the tissue. This infiltrated tissue is of a yellow 
color, has a lardaceous appearance, and is frequently of a 
very firm consistency. If the course of the parametritis is 
chronic, a thickening and fibrous degeneration of the connect- 
ive tissue takes place, which gradually continues to shrink, 
so that a displacement of the uterus is produced when the 
affection is unilateral. This chronic affection occurs inde- 
pendently of the puerperal condition in all possible affections 
(tumors, syphilitic ulcers of rectum, etc.). 

Putrid inflammation and gangrene of the broad ligaments, 
and of the whole pelvic cellular tissue also, may arise from 
various causes ; a dirty, stinking, brownish or slaty -green 
mass results, containing thick shreds of connective tissue. 
Perforation of the uterus, vagina, bladder, rectum, etc., may 
thus be brought about. 

The veins around the puerperal uterus (plexus uterinus), 
are always to be examined with care even in non-puerperal 
cases, as marantic thrombi are very liable to occur here, and 
in the corresponding place in the male. Secondary troubles 
in distant organs (emboli of the pulmonary artery), may 
thus arise. Phlebolites sometimes occur here also. 

Cysts of various size are often found either upon or within 
the broad ligaments, especially near the ovaries and the ab- 
dominal extremity of the Fallopian tubes. These cysts, 
when small, contain a jelly-like material ; most of them orig- 
inate in the parovarium, as is suggested by the fact that they 
are situated between the two layers of the ligament, and by 
their lining of ciliated epithelium, which, however, often be- 
comes squamous in the larger cysts. The parametrium very 
frequently contains cancerous nodules, when carcinoma is 
present in the uterus. 

The important evidence to be obtained from the lymphatic 



264 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

glands enclosed in the pelvic cellular tissue, when affected 
by cancer, has been referred to. They also become red and 
swollen in inflammatory processes. 

(7.) THE FALLOPIAN TUBES. 

Variations in the size and shape of the tubes are very fre* 
quent in old people. Elongations, bends, etc., may be caused 
by tumors or other affections of the uterus ; tortuous curves 
are also produced by pseudomembranes, and cystic dilata- 
tions, especially of the abdominal portion, may result from 
the closure of their openings (by adhesions, bends, oblitera- 
tion, etc.). 

Before the mucous membrane is displayed, the fimbriae (es- 
pecially in the puerperal condition) are to be examined ; 
these become swollen and dark-red in inflammation of the 
mucous membrane, and the attempt should be made to press 
out of the infundibulum any secretion (catarrhal, purulent), 
for it is possible for peritonitis to originate from inflamma- 
tion here. Still the reverse is more frequent, the mucous 
membrane of the tubes presenting only a catarrhal condi- 
tion, while a purulent peritonitis exists. 

The tubes are next to be slit open along their whole length 
from the fimbriated extremity, in order that the mucous 
membrane may be carefully examined. Simple catarrh (sal- 
pingitis), with swelling, redness, and increased secretion 
(containing abundant epithelial cells), occurs here, also puru- 
lent inflammation, and, finally, tuberculosis, which usually 
appears in connection with general tuberculosis of the gen- 
ito-urinary apparatus, and has the same appearance as in the 
uterus. The changes from tuberculosis are always further 
advanced in the tubes than in the uterus. Chronic inflam- 
mation with induration, both of the mucous membrane and 
the whole thickness of the wall, may be met with. 

Cystic dilatations are always lined with mucous mem- 
brane, the function of which varies, as it sometimes and 
most frequently secretes a watery fluid, containing many 
mucous corpuscles (hydrops tubal or hydrosalpinx), at other 



THE OVARIES. 265 

times the secretion is purulent (pyosalpinx). It is a very 
common occurrence for haemorrhage to take place into the 
interior of the dilated tube, in consequence of which the 
fluid in the so-called hydrops assumes, in most cases, a 
brown color (hydrops tubce sanguinolentus) . 

Rupture of the tubes occurs in tubal pregnancy, a de- 
tailed account of which will be given in treating of extra- 
uterine fcetation. 

(m.) THE OVARIES, 
(a.) External Examination. 

The position of the ovaries is subject to but very few 
primary changes, which consist in a greater proximity to the 
uterus, or in dislocation to some place within the recto- 
uterine fossa. On the other hand, their position frequently 
becomes changed with that of the uterus, as may be easily 
observed. 

Their average size is about half that of a pigeon's egg. 
This may vary in either direction. They may shrink to the 
size of a bean, or may attain that of a hen's egg^ even when 
free from tumors. When these are present, they may be- 
come so large as to fill the greater portion of a very dis- 
tended abdominal cavity. In considering their slxape, which 
may be altered in many ways by tumors, their general form 
(flat oval) is of much less importance than the surface ; the 
latter is perfectly smooth even at the commencement of 
puberty, but as ovulation advances it contains irregularities 
in the form of little depressions, the cicatrices of ruptured 
follicles. These increase in number when pregnancies fol- 
low, as the corpora lutea of the latter leave long, deep, cica- 
tricial depressions upon the surface. The surface of the 
ovaries of old women who have given birth to many chil- 
dren presents an extremely uneven, knobbed appearance. 

The grayish color of the ovaries of young persons is also 
subject to changes corresponding to the changes in form. 
as the cicatrices of the ruptured follicles appear of a slaty 
color, owing to transformed blood coloring matter. A gray- 



266 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

ish-white color is produced by a thickening of the tunica 
albuginea, while reddish tints result from inflammatory 
processes. 

The consistency, independent of pathological conditions, 
depends upon the number and size of the Graafian follicles 
present. The normal tissue is firm, and may become denser 
from chronic fibrous inflammation, even to such a degree as 
to be cut with difficulty. On the other hand, inflammatory 
processes may cause it to so soften as to become quite fluid. 

(5.) Internal Examination, 

In order to examine the internal structure of the ovary, 
the gland is to be divided by a longitudinal incision, corre- 
sponding to the broadest plane and extending to the hilus, so 
that the two halves may be entirely laid apart. 

The amount of blood within the parenchyma varies very 
much, according to the physiological condition of the organ 
at the time. At the menstrual period it is very consider- 
able, the cut surface is intensely red, and the full tortuous 
vessels are apparent, especially at the hilus. The condition 
is similar during pregnancy. At other times the color of 
the cut surface is not uniform, as the gray of the stroma is 
frequently interrupted by the whitish trabecule, and by the 
slaty cicatrices of ruptured follicles. 

In examining the ovary in detail, it is necessary to con- 
sider the condition of the follicles separately from that of the 
stroma, as either may undergo changes independently of the 
other. 

1. In considering the follicles, it is often desirable and 
important to know, in order to judge of the case as a whole, 
and of certain changes within the uterus, whether a recently 
ruptured follicle (corpus hsemorrhagicuni) or a true corpus 
luteum is present/ In order to determine this point, it is 
often necessary to make numerous small incisions in the di- 
rection of the original one. The corpora hemorrhagica are 
of the size of cherries, and appear as dark- or brownish-red, 
soft masses, according to their age. The recent corpus lu- 



THE OVARIES. 267 

teum is somewhat smaller (the size of a hazel-nut to that 
of a cherry-stone) ; it has a yellowish border one or two mil- 
limeters in width, which is usually somewhat zigzag (convo- 
luted), and a brown or grayish-brown interior. 

In preparations made with needles from the corpus haemor- 
rhagicum, quantities of granular corpuscles and fat granules 
are found, and in those from the corpus luteum haematoidine 
pigment, sometimes in the form of elegant rhombic crystals. 
In the course of the normal retrograde changes the fat be- 
comes absorbed, and the corpus luteum becomes converted 
into a small radiating cicatrix, colored black by blood pig- 
ment. Occasionally very firm grayish-white bodies, which 
may attain the size of a cherry, originate from the capsule of 
the follicles, and appear in the place of the corpora lutea. 
These appear upon section to be composed of a wavy, fibrous, 
peripheral portion, and a somewhat deeper seated centre con- 
taining hasmatoidine crystals, which indicate the real charac- 
ter of this fibroma folliculi (corpus fibrosum). 

The changes within the unruptured follicles are principally 
confined to their contents. An increase in the follicular fluid 
produces the very common cystic enlargement, which is some- 
times confined to single follicles, and at other times affects a 
large number. Frequently the enlargement is not extreme, 
but cysts occur of the size of a walnut or of a man's head 
(hydrops folliculoruni). The contained fluid is limpid and 
contains but few morphological elements. Sometimes it is 
possible to discover the ovum in the smaller cysts, by cutting 
them out and opening them with great care upon an object 
glass. Small cystic dilatations of the follicles occur even in 
the new-born. In puerperal affections the follicles are often 
found filled with pus (oophoritis apostematosa follicularis), 
either with or without a change in the stroma, so that they 
appear like little abscesses, the origin of which may bo rec- 
ognized by the character of their walls. Haemorrhage also 
occurs in the follicles without their bursting, especially when 
the walls are thickened by chronic inflammation. 

2. The stroma may be affected by edematous swelling, 



268 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

which very frequently accompanies the inflammatory proc- 
esses of the uterus and its appendages, and of the perito- 
neum. Acute inflammation, of which there are three vari- 
eties, the phlegmonous, thrombophlebitic, and lymphangitic, 
is also important. All have their origin and principal seat in 
the hilus and in the so-called medullary substance. The 
two latter are characterized by the changes which have al- 
ready been described as occurring in the corresponding ves- 
sels of the uterus, and the former (oophoritis phlegmonosa), 
when slight, by an infiltration of the tissue with a yellowish, 
gelatinous material, and when more severe, by an infiltration 
with pus. In many cases the inflammation has an ichorous 
character ; the swelling and softening are then the greatest, 
and perforation with resulting peritonitis is most frequent. 

Acute inflammation, which is almost always of puerperal 
origin, is much less frequent than the chronic form, which is 
sometimes confined to the outermost layers of the tunica al- 
buginea, and results in the formation of a tough, white cap- 
sule some millimeters in thickness ; at other times it involves 
the whole organ, producing fibrous degeneration and atro- 
phy (oophoritis chronica fibrosa). 

3. Among the tumors of the ovary the cystoma occupies 
an important place. One variety of cystic formation, the 
hydrops folliculorum, has already been described in speaking 
of the affections of the follicles. There is another, the true 
colloid cysts (myxoidcy stoma), which are characterized by 
their thick, viscid, frequently yellow or brownish (bloody) 
gelatinous contents. They are always multiple at the outset 
(multilocular cysts), and are usually present in large num- 
bers. In cases of long standing it often happens that one or 
several cysts are much larger than the rest, and finally there 
may be but one present (unilocular cyst), which is formed by 
the union of many smaller ones. Such a mode of origin may 
often be recognized by the presence of projections from ths 
walls, and of a more or less regular network of streaks in 
the contents, composed of fatty degenerated epithelial cells 
from the walls of the small cysts which have been destroyed. 



THE OVARIES. 269 

The inner surface of the cysts is lined with cylindrical epi- 
thelium, projections of which, resembling follicular glands, 
extend into the wall; when these are detached from their 
base they give rise in turn to smaller cysts. The latter at 
first lie within the walls, but as they increase in size they 
soon project into the interior, and produce the impression of 
their origin from the exterior. As the manner of growth of 
these cysts has a great resemblance to that of the normal 
Graafian follicles, they have been called adenomata. By a 
conversion of the colloid contents into a more fluid sub- 
stance, and by a constant secretion of liquid from the walls, 
the epithelial cells of which often perish, what is known as 
multilocular ovarian dropsy originates. Polypoid growths 
are often seen on the inner surface of these cysts, and ex- 
tend into their interior ; they are usually small, but may 
attain such a size in many cases as to fill the whole inte- 
rior, or even to break through the walls. 

The cysts may undergo secondary changes by the admix- 
ture of blood with their contents, which gives them a brown 
color. Suppuration may take place from the wall, and the 
contents may become ichorous, usually in consequence of 
operative interference (puncture). In the case of large 
cysts, adhesions to the abdominal walls, intestine, etc., are 
almost constant. 

Besides the pure (adeno-) cystomata there are a large 
number of cystic tumors of different natures, for most ova- 
rian tumors are prone to become cystic. Thus there is a 
cysto fibroma, cysto carcinoma, etc. The fibroma, in all cases 
rare, may occur pure, or in the form of fibromyoma, as in 
the uterus, but pure myoma is rare, and the fibrous ele- 
ment usually predominates, so that the tumor is hard. As 
is the case in the uterus, these tumors occur combined with 
sarcoma (fibrosarcoma, myosarcoma), but pure sarcoma is 
rare. 

Carcinoma is more common, and both the hard and soft 
forms occur. One peculiar variety, villous cancer {carci- 
noma papillosum'), which appears elsewhere only in mucous 



270 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

membranes, is frequently met with in the ovary. It seldom 
appears upon the surface of the ovary, but usually in cysts, 
and retains the general characteristics, even that of metas- 
tasis. The branched arborescent, fibrous villi, covered with 
cylindrical epithelium constituting the stroma, may be rec- 
ognized by isolating portions with needles and a brush. 
Ovarian tumors, especially cystomata, are very frequently bi- 
lateral, and are usually further advanced on one side than 
upon the other. When they are of equal size upon the two 
sides, and of a malignant nature, it may always be suspected 
that they are secondary (for instance, in cancer of the stom- 
ach). 

Finally, the ovary is the place of origin for the so- 
called organoid and teratoid tumors, i. e., those tumors in 
which whole organs, or parts of a skeleton, are produced. 
The most frequent is the appearance of skin in the so-called 
dermoid tumors or cysts, the outer wall of which consists 
of connective tissue, and the inner of epidermis ; from the 
latter both glandular and horny formations (hair) take their 
origin. The cavity of the cyst is filled with greasy, yellow 
pulp, which is more or less mixed with hair, and in which 
sebum, epidermis, cholesterine, etc., may be discovered by mi- 
croscopic examination. In other cases the reproduction of 
normal organs, and of groups of tissue, is more extensive, 
and bones, teeth, muscles, nerves, etc., may be found. 

(ft.) THE PELVIC PERITONEUM. 

The changes taking place upon the outer surface of the 
uterus, Fallopian tubes, and ovaries still remain to be con- 
sidered, and also those which the peritoneum in the recto- 
vesical fossa undergo. 

The most frequent are those caused by chronic adhesive 
inflammation (perimetritis, perioophoritis cTxron. adhcesiva^). 
False membranes of varying thickness extend from the pos- 
terior surface of the uterus to the anterior portion of the 
rectum, or to the lateral walls of the true pelvis. Others 
connect the Fallopian tubes and the ovaries with the rectum 



THE PELVIC PERITONEUM. 271 

and the lateral pelvic walls, or with the uterus ; the tubes are 
consequently often variously curved, even closed, the ovaries 
displaced, and frequently so packed in pseudomembranes as 
scarcely to be found. This process usually extends from the 
uterus, but it may also be secondary to disease in the rectum 
and elsewhere. The same form of inflammation gives rise 
to adhesions between the surface of the uterus and intes- 
tinal (large and small) coils, so that the recto-uterine fossa is 
often shut off from the rest of the abdominal cavity, a con- 
dition which may also occur in many other processes in this 
region accompanied by acute inflammatory changes. 

The chronic inflammation of the peritoneum which has 
been described as resembling pachymeningitis hsemorrhagica, 
occurs with relative frequency in the true pelvis. The haem- 
orrhages which occur in the layers of the newly formed con- 
nective tissue, give rise in the female to the so-called retro- 
uterine hematocele, the hoematoma retro-uterinum of Vir- 
chow, a blood tumor which also occurs in the same manner 
in the male within the recto-vesical fossa. The hemorrhage 
may give rise to a purulent inflammation, which may cause a 
rupture into the vagina, rectum, etc. 

Purulent inflammation may be confined to the true pelvis 
(pelvic peritonitis'), but when there are no old adhesions 
present, it usually extends over the whole peritoneum. The 
same is true with regard to the ichorous inflammation pro- 
duced by perforation of the rectum, vagina, etc. Tubercu- 
lous and carcinomatous inflammations of the peritoneum, 
especially the disseminated forms, affect this portion in a 
very peculiar, and in many respects interesting, manner. 
Frequently, when there are but very few tuberculous and 
carcinomatous nodules in other localities, their number is 
quite large in the excavatio recto-uterina, as though the 
greatest number of germs had fallen here, in the deepest 
portion of the abdominal cavity, from which the tubercles or 
cancerous nodules might have sprung. This view of their 
origin is illustrated by the frequent occurrence of echinococ- 
cus cysts in the same place, when they occur multiple in the 
abdominal cavity. 



272 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

All that has been said in regard to the recto-uterine fossa 
applies, mutatis mutandis, to the recto-vesical fossa. 

Extra-uterine foetation must not be omitted from the list 
of affections of the true pelvis. Its effects are very varied 
according to its duration, the size of the ovum, and the num- 
ber and extent of the secondary changes which are pro- 
duced in the peritoneum and surrounding organs by the 
growth of the latter. As extra-uterine pregnancy usually 
terminates in rupture and internal haemorrhage, the direct 
cause of death, a varying quantity of coagulated blood is 
found on making a post-mortem examination, either free in 
the abdominal cavity, or more or less completely confined by 
peritoneal adhesions. The recto-uterine fossa is completely 
filled with a thick mass, which might appear to be the result 
of a simple haemorrhage from the newly formed vessels of 
peritoneal adhesions, a retro-uterine hgematocele, with which 
affection these pregnancies are frequently confounded during 
life. It is consequently necessary to examine such masses 
of blood with great care. When pregnancy is far advanced 
the foetus is, of course, easily found; in the earlier stages, 
however, it is found only after most careful examination. 
The umbilical cord leads to the seat of the ovum, which may 
be so altered by chronic inflammatory processes, especially 
by adhesions to neighboring parts, as to .be recognized with 
difficulty. Different forms of extra-uterine pregnancy are 
distinguished according to the seat of the placenta ; the ah- 
dominal, which is denied by many authors, when the ovum 
is attached to any place within the pelvic cavity ; the tubal, 
when it was situated within the Fallopian tube, and by per- 
foration may have passed into the abdominal cavity ; finally, 
ovarian pregnancy, when the ovum has never left the place 
of its formation, but has become further developed within the 
ovary. In this form, it is, of course, impossible to find any 
corpus luteum, and it should, therefore, be carefully looked 
for in all cases where the ovum is attached to the ovary, and 
there is a possibility of ovarian pregnancy. In order to be 
sure of recognizing tubal pregnancy, which is divided into 



THE RECTUM. 273 

tubo-uterine or interstitial, pure tubal, and tubo-ov avian or 
tubo-abdominal, it is necessary to examine both tubes 
throughout their whole extent, to see if they are intact. 
This is often a very difficult matter, because the tubes, 
ovaries, uterus, rectum, and ovum, are bound together in one 
inextricable mass. As a rule, the ovum proper and espe- 
cially the placenta, will no longer be found in a normal con- 
dition. Nodules of varied size project from the inner surface 
of the latter, and present a dark-red, bright grayish-red, or 
grayish-yellow color. Upon section these will be found to 
consist of fresh, or old and decolorized masses of blood. 

Not all cases of extra-uterine f oetation cause death so sud- 
denly by rupture and haemorrhage. In rare cases the foetus 
dies, becomes incrusted with lime salts, and converted into a 
stone foetus (lithopcediori), which is imbedded in numerous 
dense false membranes, and is often found only by accident 
at the autopsy. In other cases, which are rather more fre- 
quent, inflammatory processes result from the pregnancy, the 
foetus suppurates, and a perforation results, usually into the 
rectum, through which parts of the foetus may be discharged. 
In other cases perforation of an adherent intestinal coil may 
occur, producing an ichorous inflammation about the ovum 
which may in turn perforate in different directions. 

(tf.) THE RECTUM. 

The rectum is to be laid open from the anus through the 
middle of the posterior wall, after the mass of pelvic viscera 
has been turned over, so that the bladder lies underneath 
and the rectum on top. 

(a.) General Characteristics. 

Among the variations in the size of the rectum there is 
found, besides the congenital complete closure (atresia ani), 
a narrowing of the lumen (stricture of the rectum) from 
cicatrices or tumors. It may be dilated by faecal masses, and, 
in rare cases, by prolapsed portions of intestine, resulting 
from invagination higher up. The latter condition must 

18 



274 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

not be confounded with prolapsus ani, which is produced 
by a displacement of the rectum itself, and is to be distin- 
guished by the fact, that in the latter the skin is continuous 
with the mucous covering of the mass which projects from 
the anus. 

Changes in the rectum affect principally the mucous mem- 
brane, still the muscular layer takes a secondary part in 
many affections ; for instance, it becomes thickened in chronic 
ulcerative processes (syphilitic and diphtheritic inflamma- 
tion, tumors), or it may be the seat of the same affections 
which have become established in the mucous membrane 
(ulceration, tumors, etc.). 

The mucous membrane not unfrequently appears thickened 
or swollen, the swelling being partly cedematous and partly 
inflammatory. As the layer beneath it (muscular) is not 
swollen, the distention can only take place with the forma- 
tion of folds. Complete absence of the mucous membrane 
only occurs as a result of syphilitic ulcers ; the diphtheritic 
ulcer, which may cause great destruction, leaves in the rec- 
tum, especially in the lower portion, a relatively intact mu- 
cous membrane. 

The color is usually gray, but frequently becomes red or 
bluish-red toward the anus, owing to the great number of 
dilated veins. In acute inflammation it becomes brighter or 
darker red ; after chronic inflammation, slaty ; the latter 
color, with grayish- white, is usually present when the mucous 
membrane is completely destroyed, especially by syphilitic 
and diphtheritic ulcers. 

The consistency is correspondingly soft and flabby in ex- 
treme cedematous swelling, firm and fibrous in chronic ulcera- 
tive processes. 

( 5.) Special Morbid Conditions. 

First among the separate affections of the rectum may be 
mentioned the dilatation of the hsernorrhoidal veins at its 
lowest part, above and at the anus (haemorrhoids). They 
appear as thick, blue, varicose projections in the mucous 



THE RECTUM. 275 

membrane ; when more developed they are in the form of 
nodules, which present upon section only thin septa of con- 
nective tissue, and contain little else than blood. They may 
attain the size of a pea, cherry, or even plum, and project at 
the anus beyond the external skin. Under certain conditions 
thrombi will be found, composed of firm or softened coagula, 
although the latter occur less frequently than might be ex- 
pected a priori. It is more frequently the case that the 
thrombi have become organized, when the nodule consists of 
a vascular fibrous tissue. Similar nodules may also arise in 
the neighborhood of the varicose vessels from hyperplasia of 
the connective tissue of the mucous membrane. 

Simple inflammation of the rectum (proctitis) may be 
acute or chronic. The first is characterized by swelling and 
marked reddening of the mucous membrane, which is covered 
with mucous secretion or a puriform mass ; the latter by the 
slaty and often completely black color of the mucous mem- 
brane. 

The syphilitic affections of the rectum are very character- 
istic, nothing analogous being observed with, certainty in the 
other portions of intestine. The condylomata belong to this 
class. They are situated at and about the anus, and are usu- 
ally produced by the flow of secretion from the female geni- 
tals, which are similarly affected, and exhibit the same con- 
dition. Recent syphilitic ulcers are scarcely met with in the 
rectum proper, but their resulting cicatrices are usually 
found. They have only been described as occurring in the 
female cadaver, their favorite seat being immediately above 
the anus and in the cloaca, which fact is important in mak- 
ing a differential diagnosis ; under certain circumstances they 
may extend higher up. The affected mucous membrane is 
replaced by a somewhat uniform, tough, fibrous, cicatricial 
tissue, which appears upon section to extend to the muscular 
coat, which is always much thickened. The diseased por- 
tion is sharply defined, so that the mucous membrane ap- 
pears at the line of junction as though cut through. The 
cavity of the affected portion of intestine is always en- 



276 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

croached upon, and sometimes there is very marked ste- 
nosis. Perforation of the ulcers, with resulting inflammation 
about the rectum (periproctitis), is occasionally met with, 
and also perforation into the recto-uterine fossa, with the 
formation of encapsuled foul exudation, which may in turn 
perforate into the abdominal cavity and quickly cause fatal, 
general peritonitis. 

Diphtheritic ulcers which have healed, resemble the syph- 
ilitic in respect to the changes produced in the intestine. 
They differ, however, very materially in their seat, as they 
are almost always situated at the commencement of the rec- 
tum (at its junction with the sigmoid flexure), or, at least, 
are more marked here, so that the affection constantly in- 
creases in extent and severity from the anus upwards. 
Moreover, according to Virchow, the diphtheritic cicatrices, 
instead of being regular and flat like the syphilitic, are 
ragged and irregular, both upon the surface and at the cir- 
cumference. The appearances of recent diphtheritis are quite 
characteristic. It always attacks first the prominent points, 
as the tops of the folds, which are, of course, not so well 
developed in the rectum as in the upper portion of the large 
intestine. At first these points appear much reddened and 
as if sprinkled with bran, later they appear as infiltrations of 
a gray, or, through the presence of fasces, of a brown color, 
which begin to involve the portions between the folds. Then 
there occurs a loss of substance, which constantly extends 
wider and deeper, till, finally, a large portion of the much 
thickened muscular coat, which is recognized by its horizon- 
tal, parallel fibres, is laid bare, and only very small islets 
of mucous membrane remain; the latter present the first 
stages of the affection (redness and haemorrhages, bran-like 
deposits), and may be easily taken for the portions which 
have suffered the greatest change, and not for those which 
are the least altered. 

Ulcers very similar to the diphtheritic forms are some- 
times found in the rectum, and are the result of very irritat- 
ing injections, for instance, vinegar. In these cases also the 



THE RECTUM. 211 

tops of the folds are ulcerated or covered with grayish in- 
filtrated mucous membrane, the contiguous portions being 
reddened and swollen. When such an affection is limited to 
a small area, the remaining portion of the intestine being 
free, a chemical cause must always be thought of. 

In all cases of wounds and ulcers situated near the anus, 
and in an otherwise healthy mucous membrane, a mechanical 
origin must always be thought of, especially when they are 
situated longitudinally. These lacerations are usually due 
to the improper use of a syringe. 

Certain peculiarities of diphtheritis, also follicular inflam- 
mation, and the changes due to tuberculosis and typhoid 
fever, will be fully described in treating of the colon. It is 
sufficient to mention here that they may occur in the rectum. 

The tumors of the mucous membrane of the rectum still 
remain to be described. Among the histioid tumors polypi 
of varied size are found, sometimes multiple, when the con- 
dition may be termed proctitis polyposa vel prolifera ; at 
other times they are solitary and of considerable size. All 
that was said concerning them in the uterus applies here, 
especially in regard to their inflammatory origin. 

The carcinomatous tumors are of more importance, of 
which there are two principal varieties, the cylindrical- cell 
and the gelatinous or colloid cancer (carcinoma colloides vel 
mucosum) ; the latter occurs here more frequently than in 
any other locality, with the exception of the stomach. Tu- 
mors seldom attain a large size here, as they are usually 
prevented by ulceration, which gives rise to an uneven and 
nodular, foul ulcer, situated, as a rule, in the middle third or 
upper half of the rectum. When the tumor is of the colloid 
variety, masses of the gelatinous material, varying in size 
from that of a pin's head to that of a millet-grain, are often 
seen upon this surface. At the circumference of the ulcer 
the mass of the tumor projects like a wall, and is sometimes 
soft (common cancer), again hard (colloid cancer, scirrhus). 
When this is cut through the medullary or colloid mass is 
presented to view. The same is the case with the bed of 



278 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the ulcer, where the wall appears more or less thickened, due 
partly to cancerous material in the submucous tissue, and 
partly to an enormous thickening of the muscular coat, be- 
tween the muscular bundles of which cancerous masses may 
be seen appearing like white threads. Sections sufficiently 
thin for microscopic examination may be made with the dou- 
ble knife. Perforation with its different results may occur 
into the vagina or the uterus, and also into the abdominal 
cavity. 

Melanoma of the rectum is very rare. 

Atresia ani is an important congenital affection of the rec- 
tum, in which the intestine does not open externally, but ter- 
minates in a blind extremity at a greater or less distance from 
the integument. The point at which it ought to open is usu- 
ally indicated by a little depression in the skin. It occurs 
not only in children born prematurely, but in those who are 
in other respects perfectly formed. 

6. THE DUODENUM AND STOMACH. 

(a.) External Examination. 

The examination of the duodenum and stomach commences 
with the inspection of their exterior, which is made by first 
placing the coils of small intestine (which were thrown up in 
removing the pelvic organs) as far down and to the left as 
possible, and by drawing the transverse colon firmly down- 
wards. The adhesions which frequently occur in the neigh- 
borhood of the descending portion of the duodenum, between 
the colon and liver, or gall-bladder, are then to be separated 
with the knife, until the stomach with the horizontal and 
descending portion of the duodenum are completely brought 
into view. The external examination is principally confined 
to the stomach. 

(1.) General Characteristics. 
The size or distention of the stomach is evidently de- 
pendent, above all things, upon the quantity of the food 



THE DUODENUM AND STOMACH. 279 

which it may contain, although this always varies but little. 
Abnormal dilatations are frequent, partly acute (distention 
from gas), partly chronic (dilatation proper) ; the latter may 
be so extreme that the greater curvature reaches down to the 
true pelvis. This affection is usually the result of stenosis 
in some of the deeper portions of the digestive tract, espe- 
cially from tumors in the duodenum ; it may be, however, 
idiopathic, being produced by constant overfilling for a long 
time, and eventual paralysis of the muscular coat. Partial 
dilatation of the fundus and cardiac extremity also occurs, 
especially in connection with stenosis of the middle portion 
from cicatricial contraction (large chronic gastric ulcers, etc.). 
When the muscular coat is greatly stretched, it is sometimes 
marked by lines similar to those in the skin of the abdomen 
when the latter is greatly distended. Contraction of the 
stomach is much more rare than dilatation. It occurs with 
relative frequency accompanying the so-called atrophying 
cancer, scirrhus, which may involve the whole mucous mem- 
brane, and cause a great diminution in the size of the stom- 
ach by the contraction of its walls. 

Variations in shape occur as congenital anomalies, in the 
form of a diminution in size at or near the middle (furrow), 
so that the stomach is of an hour-glass shape. Frequently 
the same variation is pathological, caused by cicatricial con- 
traction, which may be due to a chronic ulcer, or to a cancer 
situated at this point. Secondary variations in shape of 
different kinds, due to external mechanical influence (adhe- 
sions, tumors, etc.), are, of course, liable to be met with. 

Variations in position, either with or without a change in 
shape, are observed, and usually consist in a lower position 
of the pylorus than usual, the stomach occupying its foetal 
position (directed from above downwards) more or less. 

The color of the outer surface is usualty gray. This as- 
sumes a whitish shade similar to that of fibrous tissue, when 
the serous coat is thickened by chronic processes of various 
sorts. When the walls are softened by acid contents, they 
appear translucent, gray, and gelatinous. They appear 
blackish from the effects of sulphuric acid, etc. 



280 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

In cases of so-called softening the consistency may become 
like that of mucus, whether the softening is due to the acid 
contents of the stomach, or to poisons which have been intro- 
duced. It is increased in all those affections which are ac- 
companied by a thickening of the serous, and especially of 
the muscular, coat ; in the case of diffuse scirrhus cancer of 
the stomach, the hardness may be like that of a board (for- 
merly frequently called cirrhosis of the stomach). 

(2.) Affections of the Serous Coat. 

The serous coat of the stomach becomes involved in many 
affections of the mucous membrane, as well as in those of 
the peritoneum. Perigastritis chronica, which is frequently 
adhesive, is characterized by the thickening and white color 
of the serous covering, and by the adhesions to the liver, 
transverse colon, spleen, or diaphragm which it produces. It 
seldom extends over the whole stomach or over a great area, 
but is more frequently partial, being situated over circum- 
scribed affections of the mucous membrane (ulcers, tumors), 
and decreases in intensity towards the periphery. 

Acute purulent inflammation is, in the majority of cases, a 
part of a similar general peritonitis. There is, however, a 
peculiar form of purulent inflammation, purulent lymphan- 
gitis, which is confined to the stomach, and is due to disease 
of the mucous membrane (tumors). In these cases delicate, 
varicose (in consequence of valves) vessels, some of which 
may be one centimeter in diameter, are seen beneath the 
serous coat, filled with yellow purulent material. They orig- 
inate principally from one point, which corresponds to the 
place in the mucous membrane where the tumor is situated. 
The affection may extend to the diaphragm, and the pleura, 
when the previously described lymphangitis purulenta pleu- 
ralis and pulmonalis even results. 

The serous coat of the stomach becomes affected in gen- 
eral tubercular peritonitis, as well as in the purulent form. 
This affection is frequently not uniform, the anterior wall 
being more affected from its exposure, so to speak, to the 



THE DUODENUM AND STOMACH. 281 

tubercular germs in the abdominal cavity, than the protected 
posterior wall. Sometimes the anterior surface is found 
thickly studded with tubercles, while they are seen only in 
groups upon the posterior wall, and frequently follow the 
course of the vessels. 

Carcinomatous perigastritis may be a part of general car- 
cinoma of the peritoneum, or it may occur alone as a second- 
ary affection of the gastric mucous membrane. The latter 
is the most frequent form. Small nodules of varied size 
are seen at the point where the cancer is situated in the 
mucous membrane, which is usually indicated by depression 
and marked thickening of the serous coat, and frequently by 
adhesions. The nodules are usually arranged in groups, be- 
coming smaller and more isolated towards the periphery of 
the latter. This secondary formation of cancer may occur in 
connection with lymphangitis purulenta. The lymphatic 
glands situated especially along the lesser curvature of the 
stomach, also become involved, and undergo carcinomatous 
degeneration. 

In all cases where perforation is suspected, the examina- 
tion must be made with the greatest care. 

The post-mortem rupture of the stomach must be distin- 
guished from those forms occurring during life. In the for- 
mer case a varying quantity of the contents of the stomach 
is found free in the abdominal cavity, without any appear- 
ance of inflammatory reaction. The walls of the stomach, 
especially at the fundus, are much softened, and are fre- 
quently converted into a translucent, slimy mass. The cause 
of this change is found to be due either to abundant, strongly 
acid (fermenting) food, especially in children that have drank 
much milk, or to the presence of poisonous substances (for 
instance, sulphuric acid), which have a similar effect. The 
effect produced by perforations occurring during life, range 
according to the relations of the surrounding parts ; a com- 
munication maybe established with the abdominal cavity, or 
with a closed sack resulting from chronic inflammation, or 
the hole in the wall may become closed by the formation of 



282 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

adhesions between the stomach and other organs. In the 
first instance the result is a general peritonitis which is 
quickly fatal ; in the second, a circumscribed purulent or 
ichorous inflammation, which is frequently of long standing ; 
and in the last, as a rule, a chronic progressive ulceration. 
In such cases, it is frequently necessary to vary from the 
usual method of performing the autopsy, and to remove the 
stomach in connection with the other organs, most frequently 
the pancreas and liver. 

In the first two classes of cases the opening in the walls 
is relatively small, and in the first, frequently not more than 
one to three millimeters in diameter, but usually appears as 
though made with a punch. Very often such perforations 
are closed by very delicate adhesions, which may be acciden- 
tally torn, thus making it doubtful whether the perforation 
previously existed or was artificially made. 

Similar perforations occur in the duodenum, but less fre- 
quently. The most frequent cause here, as in the stomach, 
is the so-called chronic, round or perforating ulcer, less fre- 
quently carcinoma. 

(7>.) The Internal Examination. 

The examination of the interior is commenced by making 
a little horizontal cut with the scissors, at the lower extrem- 
ity of the descending portion of the duodenum, and cutting 
through the middle of its anterior wall from below upwards ; 
the course of the incision is then changed in the direction of 
the horizontal portion, the anterior cut edge being drawn 
upwards. The incision is continued through the anterior 
wall, as the stomach is to be opened along the greater curva- 
ture. At the junction of the duodenum with the stomach, 
the blade of the scissors must be pushed forward as nearly 
as possible in the axis of the canal, otherwise it may catch 
against the fold which is formed by the projecting sphincter. 

The stomach is to be opened at first only as far as the 
fundus, that the contents may be easily removed with a 
cup. 



THE DUODENUM AND STOMACH. 283 

(1.) The Contents. 

In opening the duodenum it is necessary to notice both the 
nature and quantity of the contents, also any difference in 
them which may exist above and below the papilla of the 
gall duct, and the presence of biliary coloring matter in the 
lower part, or in the upper as well. 

In examining the contents of the stomach, the quantity, 
color, consistency, reaction, smell, and composition, and espe- 
cially the morphological ingredients that may be present, 
are to be noticed. This is not only necessary in judging 
of the contents, but also of the mucous membrane, for pe- 
culiar post-mortem changes of the latter are produced by 
the contents under certain circumstances. For instance, 
there are numerous substances which, owing to their acid 
nature, possess the property of producing a kind of diges- 
tion of the mucous membrane, having nothing to do with 
pathological changes. The alteration may extend beyond 
the mucous membrane, finally involving the entire walls 
(softening of the stomach), when the contained food is of 
a kind liable to undergo acid fermentation, as is the case 
with milk, for instance. The reaction of the contents may 
often be recognized by the smell, but is determined accu- 
rately by the use of litmus paper. 

A bloody condition of the contents, caused by swallowing 
blood, or by a direct admixture of this fluid, deserves careful 
consideration. When blood which has come from the lungs 
is swallowed, it is filled with air bubbles and is frothy, while 
that which has come directly from the stomach is devoid of 
air bubbles, and is either in the form of large, compact, dark- 
red masses (haemorrhage from a large vessel), or uniformly 
mixed with mucus (haemorrhage by diapedesis in cirrhosis, 
inflammation, etc.), or in the form of small, dark-brown 
masses resembling coffee-grounds (old haemorrhages from 
numerous small vessels, cancer). A yellowish or greenish 
tinge is due to biliary coloring matter. The contents arc 
often of a leek-green color, when the digestive tract is ob- 
structed, and in general peritonitis. 



284 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

Besides the various admixtures of coarse morphological 
substances that may often be recognized with the naked eye 
as remnants of food, and the non-edible things that may be 
accidentally or purposely swallowed (coins, sticks, toys, 
needles, stones, etc.), there are a number of parasites 
that may be met with. With regard to remnants oj ? food, 
peculiar roundish, white or yellowish-white, brittle clumps, 
are sometimes found in the stomachs of young children, 
and are composed wholly of coagulated milk, as may be 
easily proven by microscopic examination. Similar masses 
composed of fat (mutton or beef tallow) occur less frequently 
in adults. 

Animal parasites are rarely found (only a variety of as- 
caris is sometimes met with) ; on the other hand, the vegeta- 
ble growths are very common. These, of course, can only 
be recognized with accuracy by the use of the microscope. 
The thrush parasite, which was described as occurring in 
the cavity of the mouth and oesophagus, occurs in the stom- 
ach, but much less frequently than in the former localities, 
and is found rather on the walls than in the contents. On 
the other hand, a form of parasite resembling the leptothrix 
of the mouth, is very frequently met with in the contents. 
The greatest development is in those cases where the fluids 
of the stomach are undergoing fermentation, and especially 
where that organ is distended. Besides the leptothrix, a 
parasite resembling the yeast plant is always present in large 
quantities, and also the sarcina ventriculi. The former is in 
the form of small oval bodies, which often contain glistening 
oil drops, and are frequently arranged like a chain (also 
branched). The latter consists of small bodies resembling 
dice with rounded corners, which present on each surface a 
furrow in the shape of a cross, so that four planes of equal 
size are formed. This shape has been compared to a well- 
bound bale of goods. These bodies usually lie together in 
large clumps, which in turn often possess the dice form ; 
they are often present in inconceivably large numbers in 
the lower stratum of the contents of a distended stomach, 
and the frequent brown color of the latter is due to them. 



THE DUODENUM AND STOMACH. 285 

The secretion of the gastric mucous membrane will be 
considered hereafter, as it can be examined best in connection 
with the consideration of that subject. 

(2.) The Duodenal Mucous Membrane. 

After the removal of the contents of the duodenum, the 
examination of its mucous membrane is to be continued. 
What will be said hereafter about the changes in the other 
portions of the small intestine or stomach will apply here, 
except that the duodenum presents those alterations which 
proceed from the lymph follicles much less frequently, and 
in a much smaller degree, than the lower portions of the small 
intestine. In this class are included follicular abscesses and 
ulcers, tubercular ulcers, and the changes occurring in ty- 
phoid fever, the latter being relatively the most frequent. 
It presents, on the other hand, certain changes that do not 
occur in the other portions of intestine. Among them is the 
chronic ulcer of the duodenum, which resembles the so-called 
round ulcer of the stomach, and like it tends to perforate 
into the abdominal cavit}^ or into other organs (including 
the aorta), and in this way may cause death. Among the 
causes of these ulcers are very extensive burns of the integu- 
ment. The changes (ulceration) that may arise from the 
presence of gall stones within the biliary tract are also 
peculiar to the duodenum, as well as those resulting from 
cancer of the head of the pancreas. 

Finally, perforation sometimes takes place, especially in 
the lower portion, by the side of an aneurism of the aorta 
or of one of its large branches. 

(3.) The Gastric Mucous Membrane. 

In order to examine the mucous membrane of the stomach 
carefully, it is best to remove the organ from the body. It 
may be desirable under certain circumstances (ulcers with ad- 
hesions, etc.) to remove it in connection with other organs.' 
The lesser curvature is grasped, drawn downwards and sep- 
arated from its surroundings, the lower end of the oesophagus 



286 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

and a small piece of the horizontal portion of the duodenum 
being removed with it. 

(a.) G-eneral Appearances. 

That portion of the contents, which still remains adherent 
to the inner surface is to be removed with a small stream of 
water. 

1. The secretion of the mucous membrane is then to be 
carefully examined. As is well known, the gastric mucous 
glands are confined to the pyloric portion, and consequently 
their secretion is to be looked for here. Usually there is 
only a very thin layer of mucus present, which may, how- 
ever, under certain circumstances, be greatly increased, so that 
the whole surface is completely covered with a thick layer. 
The character of this mass varies greatly : sometimes it is 
soft, opaque, and gray ; at other times transparent, and so 
tenacious that it can only be scraped off with great difficulty. 

The last condition is characteristic of acute gastric ca- 
tarrh, while the first occurs more frequently when the affec- 
tion is chronic. The mucus may also contain various ad- 
mixtures, as blood, or gall, which change its color. It has 
already been mentioned that a uniform admixture of blood 
is due to a very slight haemorrhage from a large number of 
small vessels. 

2. The changes in volume of the mucous membrane consist 
chiefly in thickening of the same. This may be determined 
by the examination at the point of junction with the oesoph- 
agus. Normally the lower, jagged edge of the oesophageal 
mucous membrane projects over that of the stomach ; when 
the latter is thickened this relation is changed, so that both 
either occupy the same level, or the mucous membrane is the 
more prominent. Very frequently the mucous membrane is 
thrown into folds when it becomes hypertrophied (chronic 
catarrh), as the muscular layer, which is not increased, is no 
longer large enough to remain everywhere in contact with 
the hypertrophied mucous coat. The folds which are caused 
by a contraction of the muscular coat (on the same principle) 



THE DUODENUM AND STOMACH. 287 

must not be confounded with the above. They disappear if 
the walls of the stomach are stretched in a direction vertical 
to them, while in the former case they will remain under 
similar treatment. Not every enlargement of the mucous 
membrane causes folds, as there may be more or less swelling 
(oedema), which produces only an increase in thickness; this 
may be very marked, but the mucous membrane is soft and 
gelatinous. Partial thickening of the mucous membrane fre- 
quently appears in the form of little granules, or larger wart- 
like growths, which are caused by chronic gastric catarrh, 
and which will be fully described in treating of that subject. 

3. The color of the mucous membrane, and the quantity of 
blood contained in it, are of great importance. The normal 
membrane is gray and translucent, and, as a rule, but few 
vessels filled with blood are found, and these are situated at 
the cardiac extremity, and at the fundus. An extensive, 
and more or less uniform redness usually points to an inflam- 
matory process. In examining the blood-vessels, it must be 
borne in mind that the arteries terminate in capillaries in the 
deeper layers of the mucous membrane, so that only venous 
capillaries and very small veins are found upon the surface. 

The color, besides being varied by the amount of blood 
present, may depend upon different pathological processes. 
As has already been stated elsewhere, a slaty color, which 
was brownish during life, and was changed to black by gases 
containing sulphur, points to previous hyperemia (gastritis 
chronica). Biliary coloring matter produces, especially in 
icterus neonatorum, a jaundiced color. Finally an opaque, 
yellow color, is of importance, due to cloudy swelling and 
fatty degeneration of the glandular epithelium. 

4. In order to be able to judge accurately of the patho- 
logical changes in the gastric mucous membrane, it is neces- 
sary to have a perfect knowledge of the great number of 
post-mortem changes which it undergoes. It has already 
been stated that these depend in great measure upon the 
quantity and character of the contents, and arise, aside from 
decomposition, especially from acids. The post-mortem 



288 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

changes are, as a rule, most intense at the fundus, where 
the contents collect. The least degree of acidity produces 
a gray opacity; when greater, a sort of digestion of the 
mucous membrane itself follows, so that it is converted into 
a soft, slimy, transparent mass, which is easily scraped off, 
and then the submucous tissue, or muscular layer, is laid 
bare. Finally, the softening may go still further and involve 
the muscular and serous coats, when the already described 
softening of the stomach results. If this occurs in a stom- 
ach free from blood, it is termed white softening ; if, on 
the other hand, the vessels are filled with blood, this is af- 
fected by the acid so as to present a brown or brownish- 
black color, the neighboring parts are infiltrated with the 
coloring matter, and a soft, more or less brown mass, re- 
sults, — brown softening of the stomach. A dirty green color 
is due here, as in most other organs, to actual putrefaction. 

(5.) Special Morbid Conditions. 

The most frequent of the inflammatory affections are acute 
and chronic catarrh. The acute form is especially character- 
ized by the large quantity of tough, transparent mucus, and 
by reddening of the mucous membrane ; the chronic, by abun- 
dant, soft, gray mucus, projections of the mucous membrane, 
and by the slaty color that occurs, especially near the pylorus. 
Besides these simple inflammations a second form occurs (espe- 
cially in drunkards), which is characterized by circumscribed 
hypertrophies of the whole mucous membrane (gastritis 
proliferd), and produces little warty projections (gastritis 
verrucosa} ; later, larger polypoid growths result (gastritis 
polyposa). Dilatation of the glands, due to compression at 
their outlet, very frequently accompanies hypertrophy here, 
as was stated with regard to the uterine mucous membrane, 
so that small cysts result, which are especially met with on 
the divided surface of the polypoid growths. In order to 
determine the part taken by the separate elements of the 
mucous membrane in the process of hypertrophy, thin sec- 
tions made with the scissors, and then torn apart, answer 



THE STOMACH. 289 

every purpose. An attempt may also be made to obtain a 
section with the double knife. The arrangement of the pig- 
ment between the glandular tubes in cases of slaty discolora- 
tion of the mucous membrane can be best recognized in a 
horizontal section, made from the surface with the scissors. 

The next in frequency is what is called by Virchow paren- 
chymatous inflammation (gastritis parenchymatosa vel glan- 
dularis vel g astro adenitis), and like the corresponding affec- 
tion of the kidneys, liver, etc., which appear in certain cases 
of poisoning (phosphorus, arsenic), in acute infective dis- 
eases and similar affections (acute atrophy of the liver), con- 
sists in a cloudy swelling, and, at a later stage, fatty degen- 
eration of the cells of the gastric glands. In this affection 
the mucous membrane generally appears to the naked eye 
swollen and opaque, at a later stage, yellow. In horizontal 
sections made with the scissors, the gland cells at an early 
stage of the fatty degeneration, may be seen to be filled with 
dark granules. These do not disappear upon the addition of 
a weak solution of caustic potash, like the granules that nor- 
mally make their appearance in the formation of the gastric 
juice, and they are thus proven to be fat granules. When 
the process is more advanced, the glandular tubules are com- 
pletely filled with fat granules, which become converted into 
little drops, and a similar appearance may be seen in the 
intertubular tissue. 

Inflammation of the submucous tissue (gastritis phlegmo- 
nosa), which is accompanied by marked swelling not only of 
this but also of the mucous membrane, is rare, and only oc- 
curs in certain infective diseases, for instance, in malignant 
pustule, where the membrane may become so changed as to 
resemble a carbuncle. Suppuration of the submucous tissue 
is extremely rare. 

2. Haemorrhage into the gastric mucous membrane is of 
common occurrence, both as a result of simple stagnation, 
and of inflammation. It appears very frequently in the vi- 
cinity of the cardiac portion and in the fundus, its favorite 
seat being the tops of the folds. It may be either recent, 

19 



290 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

when it possesses the bright or dark-red color of clotted blood, 
or old, when it will have assumed a more black or blackish- 
brown color. In the latter case, small losses of substance in 
the mucous membrane are frequently seen, and will be di- 
rectly considered. 

3. Peculiar to the stomach is the occurrence of the simple 
ulcer, which is so frequently found in its different stages, es- 
pecially in females. The simplest variety is a very shallow 
loss of substance, round and often oblong in shape, which is 
usually situated on the tops of the folds, the long axis cor- 
responding to that of the folds ; upon its base blackish or 
brownish masses composed of blood are frequently found, 
and easily scraped off. Small unaltered haemorrhages in the 
mucous membrane are frequently observed in the neighbor- 
hood of these ulcerations, and directly suggest that the gas- 
tric juice dissolves the mucous membrane at these points, 
and a loss of substance results, which has been termed hcem- 
orrhagic erosion. These occur very frequently with stasis in 
the gastric veins in disease of the liver, heart, or lungs, and 
often also after severe vomiting. 

The so-called simple, round, or perforating gastric ulcer 
(ulcus ventriculi simplex, rotundum, perforans'), appears 
quite different from these slight losses of substance. It 
varies from the size of a five cent piece to twice that of a 
silver dollar and over, and possesses a sharp border, as if 
made with a punch. They are always situated along the 
lesser curvature, or in its immediate neighborhood, and are 
funnel-shaped. They do not penetrate the walls regularly 
but in the form of terraces, so that the loss of substance is 
greater in the mucous than in the sub-mucous tissue, greater 
in the latter than in the muscular coat, and in the muscular 
greater than that in the peritoneal coat, except, of course, 
where the ulcers do not extend beyond the mucous and sub- 
mucous layers. The axis of the funnel-shaped cavity formed 
by the ulcer, does not extend perpendicularly through the 
walls of the stomach, but obliquely, from within and below 
(from the pylorus) outwards and upwards (towards the car- 



THE STOMACH. 291 

dia), L e. in the direction taken by the branches of the gas- 
tro-duodenal artery ; the edges are much more abrupt to- 
wards the cardia than towards the pylorus. Upon very care- 
ful examination, it is possible to find the stump of a small 
vessel in the deepest portion of many of these ulcers ; others 
are covered with a blackish-brown mass like the hasmor- 
rhagic erosions, which make it extremely probable that many 
of these ulcers differ from the erosions only in degree, i. e., 
they are also hemorrhagic ulcers. Microscopic preparations 
show only a thin layer of tissue at the base of the ulcer, 
infiltrated with small granules possessing a dark contour. 
The surrounding tissue is devoid of all inflammatory infil- 
tration, and there is an entire absence of purulent disinte- 
gration or necrosis. 

The termination of these ulcers is various. Many heal 
after more or less of the wall is destroyed, when a white 
stellate cicatrix results, which is often difficult to find. Oth- 
ers extend constantly deeper and wider, and may cause 
death in two ways. They either perforate into the abdom- 
inal cavity and produce a fatal peritonitis, or they cause the 
opening of some large vessel and a fatal haemorrhage results. 
If it is desired in such a case to find the opened vessel, it 
is best, after the stomach has been opened and washed, to 
inject the coronary arteries with water, when it will spurt 
from the eroded branch. 

They may terminate in another way. The walls may be 
eaten through, but perforation into the abdominal cavity 
is prevented by adhesions to other organs (pancreas, liver, 
spleen). The advance of the ulcer is not prevented by this 
means, but it extends into the adherent organ, and may at- 
tain a very large size. In such cases it is well to remove 
together all the organs that are involved, which are usually 
held together by firm adhesions, as the examination can thus 
be made more conveniently in all respects. 

4. Next in the list, after the ordinary gastric ulcers, are 
the new formations, of which the tuberculous and cancerous 
are among the first to be mentioned, as they almost invana- 



292 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

bly appear in the form of ulcers (ulcus tuberculosum, carci- 
nomatosura). Disseminated miliary tuberculosis scarcely 
ever occurs in the stomach, although a structure appears in 
the mucous membrane in certain cases, namely, the lymph 
follicles, which may be easily mistaken for tubercles. These 
follicles have precisely the same appearance and the same 
characteristics as those in the intestine. They are gray, 
slightly prominent bodies, of the size of a pin's head, and 
uniformly distributed over the whole surface, or situated 
more upon one side or the other. If a vertical section is 
made with the scissors, the tubules may be seen to be pressed 
apart by the interposed follicle, which is composed of lymph- 
oid cells closely crowded together, and contains small vessels. 
The presence of vessels, together with the entire absence of 
cheesy degeneration in the centre, form the surest guide in 
distinguishing them from tubercles. These follicles may be- 
come involved in inflammation like those of the intestine. 

Tuberculous ulcers^ which are rather rare, and, as a rule, 
seldom attain any considerable size, do not differ in their ap- 
pearance from those of the intestine, which will be described 
hereafter in detail. 

The cancerous growths are most often seated at the two 
extremities of the stomach, at the cardia and pylorus ; the 
pyloric end being far more frequently affected. Three dif- 
erent forms may be distinguished, the soft (medullary) 
glandular cancer, the atrophic (scirrhus), and the colloid or 
gelatinous form. The statement that they appear generally 
in the form of an ulcer, applies to all three, a peculiarity that 
is evidently attributable to the effects of the gastric juice. 
Only the first class, the simple glandular carcinoma, appears 
in two forms, as ulcerated and as fungous growths ; the latter, 
as the name indicates, are characterized by the formation of 
a large fungous mass, which projects beyond the general sur- 
face. Of course, ulceration upon the surface of these is not 
excluded, but the growth predominates, and a potiori jit de- 
nominate. 

It is not difficult to distinguish the three forms in well- 



THE STOMACH. . 293 

marked cases ; simple glandular carcinoma is, as a rule, very 
soft, rich in cells, and admits of cancer juice being easily 
pressed from the cut surface ; this fluid contains well-marked 
cylindrical cells, especially in the fungous variety (conse- 
quently also called cylindrical-cell epithelioma). This form 
is also frequently very vascular, and the fungous growth is 
often so richly supplied with large vessels, that the term 
telangiectodes seems appropriate. This formation gives rise 
to numerous small haemorrhages, and causes the contents of 
the stomach to appear like coffee-grounds. 

The characteristics which belong to the scirrhous form in 
all other localities are especially well marked in the stomach, 
namely, the abundant formation of a tough, white, fibrous 
tissue, that creaks under the knife ; forms even occur in the 
stomach in which the development of cancer cells is rela- 
tively very slight, and in which it is impossible to discover 
the least trace of cancer juice. Frequently it is only possible 
to determine their real character after a most thorough 
microscopic examination. It is relatively often the case 
that the new formation extends over the whole stomach, or 
the greater part of it, and the various forms of so-called in- 
duration of the stomach, gastric cirrhosis, are produced, which 
for a long time were not considered as cancerous. It also 
produces a diminution in the size of the whole organ, by the 
contraction of the newly-formed fibrous tissue, which has 
already been referred to. 

Gelatinous cancer is recognized by little, transparent 
clumps of colloid material in the meshes of the gray net- 
work of the stroma, which are most distinct at the oldest 
portions. It must not be forgotten that only t3 7 pical cases 
can be distinguished by this appearance, and that numerous 
cases occur which can only be recognized by microscopic ex- 
amination. This is especially true of those forms in which 
ulceration is the most prominent characteristic, and the mass 
of the tumor is consequently reduced to a minimum. It is 
then necessary to make sections perpendicularly through the 
edges, especially where they appear slightly everted, and 



294 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

through the base, extending to the serous coat. The mus- 
cular coat is always involved in the formation, both actively, 
as the muscular tissue becomes thickened, and also passively, 
as the growth pushes forwards into the spaces between the 
muscular bundles, and even extends through them, frequently 
forming nodular masses in the subserous tissue. The latter 
being the part in which the disease is still progressing, micro- 
scopic sections, which may be easily made with the double 
knife, should be taken from here. 

A careful examination of sections made through the edges, 
or horizontally through the base of the ulcer, is necessary in 
all cases where a differential diagnosis is to be made between 
cancerous and simple ulcers. Although small hemorrhagic 
ulcers of typical shape differ greatly from well-developed 
cancerous forms, larger ones, on the other hand, which have 
nearly lost their peculiarities, may be confounded with the 
latter, when the growth of the tumor is very slight ; then 
the} 7 " can only be discriminated by the most careful micro- 
scopic examination. The diagnosis will be greatly aided by 
examining the epigastric lymphatic glands, which are almost 
always involved in cancerous degeneration. 

There is but little to be said concerning the remaining 
forms of tumors of the stomach. Sarcoma occasionally oc- 
curs and originates in the submucous tissue. The ordinary 
well-known methods of examination are used for its diagno- 
sis. Small myomata (usually from the size of a millet-grain 
to that of a bean) also occur, and arise from the muscular 
tissue, the mucous membrane over them being freely mov- 
able ; there may be also a combination of the two forms, 
myosarcoma, and finally lipomata, etc., may be found. 

5. In conclusion amyloid degeneration is to be considered, 
and it is seldom absent in extreme cases affecting the intes- 
tines. The walls of the vessels constitute the essential seat 
of the change, although the tunicas proprise of the glands 
may be affected in severe cases. In applying the iodine test 
to this change, there is danger of deception, owing to the 
unclean condition of the surface (especially from starch in 



THE STOMACH. 295 

food), and it is therefore absolutely necessary to remove all 
the mucus, etc., by scraping and washing, from the place 
where the test is to be applied. It is also necessary to choose 
a point which is as free from blood as possible, as this fluid, 
when acted upon by iodine, gives a color similar to that 
produced by amyloid material and this reagent. 

(c.) The Stomach in Cases of Poisoning. 

Cases of poisoning demand special consideration, both on 
account of the peculiar appearance of the stomach, and their 
medico-legal importance, and especially as they require a 
different method of examination. 

1. Method of Examination. In order to observe at once 
and on the same preparation the effects of corrosive poison 
in different places along the digestive tract, the physician is 
recommended to remove the organs of the throat and the 
oesophagus first, in connection with the stomach and duode- 
num, and in opening the oesophagus to extend the incision 
along the greater curvature of the stomach. In medico- 
legal cases, the Regulations direct that when poisoning is 
suspected, the internal examination is to begin with that of 
the abdominal cavity, and that before taking any further 
step, the external appearance of the upper abdominal organs, 
their position and degree of fullness, the condition of their 
vessels, and whatever smell they may happen to possess, are 
to be ascertained. u In considering the vessels it is necessary 
to determine, here as in other important organs, whether 
arteries or veins are being dealt with, whether the smaller 
ramifications also are filled, or only branches and trunks 
of a certain size, and whether the distention of the canal 
is great or not." The left lobe of the liver is then to be 
raised, and by pulling on it, the diaphragm is drawn as far 
downwards as possible, that the oesophagus may be tied just 
above its entrance into the stomach and just below the dia- 
phragm. The oesophagus ought not to be separated from its 
surroundings by a cutting instrument, as it is liable to be 
wounded in so doing, but should be isolated more in accord- 



296 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

ance with the method employed in ligating arteries in the 
living subject, by the use of a director, scalpel- handle, or 
forceps. The duodenum is to be tied in two places in a sim- 
ilar manner, below the entrance of the gall duct, and prefer- 
ably at the end of the descending portion. Care must be 
taken here also that the ligatures are situated at a certain 
distance from each other (two to three centimeters), other- 
wise they may be easily cut or may slip off, when the intes- 
tine between them is cut through. " The stomach is then 
to be removed in connection with the duodenum, all possible 
injury to them being carefully avoided." 

They are opened in the usual way. After the contents 
have been examined in the manner already mentioned, they 
are to be put into a glass or porcelain vessel, in which the 
stomach and duodenum are also placed after being further 
examined. The Regulations give the following detailed 
directions concerning the examination : " The mucous mem- 
brane is to be washed off, and examined with regard to its 
thickness, color, surface, and consistency, special attention 
being paid at the same time to the condition of the blood- 
vessels and the texture of the mucous membrane, and every 
part is to be noted separately. It is very necessary to 
determine whether the blood which is present is within the 
vessels or outside of them, whether it is fresh or altered by 
putrefaction, or softening (fermentation), and in this con- 
dition has infiltrated (been imbibed by) the neighboring tis- 
sues. If the blood has escaped, whether it lies upon the sur- 
face or within the tissue, whether it is coagulated or not, 
etc." 

"Finally, particular attention is to be paid to the con- 
tinuity of the surface, with reference to the presence of losses 
of substance, erosions, or ulcers. It must always be borne 
in mind whether certain changes may not have possibly been 
produced by natural post-mortem decomposition, from the 
action of the fermenting contents of the stomach." 

The remainder of the examination is made in the usual 
manner, except that the oesophagus is ligated "near the 



THE STOMACH. 297 

neck " before being taken out, and is then cut off above the 
ligature and put in the vessel containing the stomach. In 
those cases where the stomach contains but little, the con- 
tents of the jejunum are also put in the same vessel. " Fi- 
nally, other substances and parts of organs, as blood, urine, 
pieces of liver, kidney, etc., are to be removed from the 
body, and given to the legal authority for further examina- 
tion. The urine is to be kept in a vessel by itself, and the 
blood also in those cases where it may be possible to draw 
important conclusions from a spectrum analysis. All the 
other material is to be put in one vessel." 

2. Changes produced in Poisoning. The substances which 
commonly~cause poisoning may be divided into two classes, 
according as they do or do not corrode the surface. The 
two act differently, the former by causing a direct lesion of 
the mucous membrane, the second by entering the blood, and 
thus causing changes in different organs, which are injurious 
only secondarily. To the first class belong the alkalies, a 
great number of mineral acids, as sulphuric, hydrochloric, 
nitric, and also a few vegetable acids, as oxalic, etc. To 
the second group belong phosphorus and arsenic, substances 
which produce marked anatomical changes in the organs, 
and the alkaloids, hydrocyanic acid, etc., which do not cause 
any appreciable changes, death being caused by the effects 
upon the nervous system. 

(a.) The changes produced by the substances belonging 
to the first group vary considerably according to the nature 
of the substance ; still the differences are not so great, as was 
formerly supposed, especially when the effects are produced 
by large quantities. The alkalies cause a marked swell- 
ing of the mucous membrane, and later of the submucous 
tissue and muscular coat also, which become converted into a 
soft, greasy, brown, or blackish mass. The acids, on the 
other hand, especially nitric, when their action is not in- 
tense, first produce a parchment-like induration of the sur- 
face of the mucous membrane, of a yellowish, brownish, or 
blackish color. This, however, becomes converted after con- 



298 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

tinued or very intense action, into a brown or black pulp, 
very similar to that produced by alkalies. The muscular 
layer of the oesophagus and stomach is strongly contracted, 
so as to diminish greatly the size of the lumen and to throw 
the mucous membrane into folds. As may be readily under- 
stood, the changes are most marked in those places where 
the substance remains longest in contact with the surface, 
consequently the effects are found to be only slight in the 
mouth and oesophagus, and along the lesser curvature of the 
stomach, and between the very prominent folds produced by 
the strong contraction ; on the other hand, they are the most 
intense at the fundus, and along the tops of the folds. It 
not unfrequently happens that the action is so intense at the 
fundus that the whole thickness of the walls is found soft- 
ened and perforated. An opposite condition of things may 
occur, especially when there is but a small amount of fluid 
taken, for this may run along the lesser curvature as far as 
the pylorus, where its further progress is obstructed, and con- 
sequently its effects greatest. On account of the slight in- 
tensity of the poisoning, the individual lives longer, so that 
at the autopsy, only ulcers, or even firm cicatrices, which may 
cause more or less stenosis, are found. In the most severe 
cases of poisoning, the blood in the gastric veins is very often 
altered in such a manner as to be converted into a black 
mass, that is often quite firm, and distends the vessels. The 
effects of the substance are not confined to the digestive 
tract, but constantly extend to the contiguous organs, within 
which the blood contained in their vessels undergoes the 
above change. The spleen, liver, heart, and left lung, are 
the organs most frequently affected. 

(5.) The condition produced by poisoning with phosphorus 
or arsenic is entirely different. Here there is absolutely no 
trace of deep corrosion, and even inflammatory hypersemia 
and haemorrhages are only met with when death has been 
sudden. Of course it is not intended to state that no ulcera- 
tive process can then arise, though if produced it is the re- 
sult of accompanying circumstances (for instance, pieces of 



THE COMMON BILE-DUCT. 299 

matches swallowed at the same time, vomiting, etc.). The 
changes produced are parenchymatous inflammation of the 
liver, kidneys, heart, and stomach, all of which have been or 
will be considered under their respective heads. Poisoning 
by arsenic may often be diagnosticated by a portion of the 
poison appearing in the mucus in the form of a white de- 
posit, which is found under the microscope to be composed 
of octahedral crystals. 

7. EXAMINATION OF THE LIGAMENTUM HEPATO-DUODE- 

NALE. 

Before removing the liver from the body the lig amentum 
hepato-duodenale, together with the ductus communis chole- 
dochus and portal vein, are to be examined. 

(a.) The Common Bile-Duct. 

The bile and pancreatic ducts have a common opening in 
the posterior wall of the duodenum at a point where there is 
a slight projection (longitudinal fold), the papilla of the gall- 
duct. In order to find the opening quickly, the head of the 
pancreas, which is easily felt, is to be sought for, the intes- 
tine stretched out transversely, and the papilla will be seen 
situated just below the middle of the head. The next step 
is to see whether the duct is pervious in its whole extent, 
more especially in the duodenal portion, the stoppage of 
which by catarrhal secretion gives rise to the so-called catar- 
rhal icterus. In order to determine this latter point the 
gall-bladder must not be pressed upon, as the force thus 
produced is too great, and no conclusions can be drawn as 
to the condition during life ; but the duct itself is to be 
pressed upon in a direction towards the intestine to see if 
the bile is forced through. While this is being done the 
papilla is to be carefully watched, as the plug, composed 
principally of desquamated epithelium, which closes the duct 
is often very small, and therefore liable to be overlooked. 
After this part of the examination is completed, the gall- 
bladder is to be pressed upon to see if the duct is pervious 



300 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

throughout its whole extent, and then a probe is to be intro- 
duced (care being taken at the same time to introduce it 
into the pancreatic duct), and the duct slit open with the 
scissors. 

The size of the duct is to be observed, the color of its sur- 
face, and its other conditions. The normal size is about that 
of a small goose-quill. Under pathological conditions it 
may attain that of a large finger. The usual cause of this 
dilatation is the presence of gall-stones, and, consequently, 
when it exists one may conclude with tolerable certainty that 
gall-stones were present here for a long time, although they 
may not be found at the autopsy. The color of the surface 
is of great importance in determining the point whether bile 
flowed through the duct during life or not, or how far it was 
possible for it to advance. When an obstruction existed at 
any point, only that portion posterior to it is colored with 
bile, the lower portion being uncolored; in this connection 
the amount of coloring caused by the bile in the oblique 
extremity of the duct, the portio duodenalis, which passes 
through the intestinal walls, is of great importance in the 
recognition of simple catarrhal icterus. 

Among the remaining alterations of the surface are the 
ulcers, which are also most frequently caused by gall-stones. 
They are usually situated at those points where the stones 
are wedged in, i. e. at the entrance of the duct into the intes- 
tine, also in front of the portio duodenalis. A 'perforation of 
the walls of the duct and of the intestine may be caused at 
this point by ulceration, so that there will be two openings 
leading into the small intestine, a large one produced by the 
ulceration and extending perpendicularly through the wall, 
and a smaller passing through obliquely — the physiological 
duodenal portion of the duct. The former opening may 
become obliterated after the gall-stone or stones have been 
discharged. In such a case it is still possible to judge of the 
previous conditions by the dilatation of the duct, and by the 
cicatrix at the above-mentioned point. Complete closure of 
the common gall-duct may result from ulceration, or rather 



TEE PORTAL VEIN. 301 

from the cicatrix produced by it, and usually occurs also in 
the duodenal portion. Purulent and diphtheritic inflamma- 
tions are very rare here, though they occasionally occur in 
diphtheritic dysentery, typhoid fever, etc. ; tumors are also 
exceptional, though small papillary growths of the mucous 
membrane are sometimes seen near the orifice of the duct. 

(b.) The Portal Vein. 

Another very important structure lies within the ligamen- 
tum hepato-duodenale, viz., the portal vein, which is easily 
found behind the common duct. The surface and surround- 
ings of the vessel are first to be examined, as very important 
inflammatory changes (periphlebitis portalis) are sometimes 
found here. These are either acute and purulent (periphle- 
bitis apostematosa) or chronic, with a resulting formation 
of fibrous tissue and contraction of the same (periphlebitis 
chronica fibrosa). The acute forms especially are usually con- 
tinued from the neighboring parts, and when this is the case 
they too must be carefully examined. The trunk of the vessel 
is then to be opened throughout its whole length, that the 
condition of its walls and contents may be examined. The 
walls may be somewhat contracted in parts, owing to chronic 
periphlebitis, in consequence of which the canal is narrowed, 
whilst, on the other hand, it may be dilated and the walls 
rendered thinner. The condition of the contents is most im- 
portant ; they may consist of liquid or clotted blood, which 
may be variously altered, and of pus or morbid growths. 

Simple thrombosis is sometimes found in connection with 
cirrhosis of the liver, as a result of pressure from tumors, 
etc. Softened thrombi, or those mixed with pus, occur as- 
sociated with inflammation of the wall (thrombophlebitis). 
These conditions usually commence at the roots of the portal 
vein ; they are most common in new-born infants, in conse- 
quence of thrombophlebitis of the umbilical vein, but often 
occur in adults, as a result of disease of the intestine, espe- 
cially in cases of perityphlitis. A purulent periphlebitis may 
also lead to secondary thrombosis and perforation of the wall 



302 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

with the escape of pus into the canal, where it becomes mixed 
with the softened thrombus. Cancerous masses sometimes 
perforate the wall from without and grow in the vein, thus 
acting as a cause for the formation of a thrombus. 

8. THE GALL-BLADDER AND LIVER. 

After completing the examination of the common gall-duct 
and portal vein, which is carried as far as possible while they 
are in situ, the relation between the liver and gall-bladder 
and their surroundings is to be determined, if this has not 
already been fully ascertained. The liver is then to be re- 
moved from the body for further examination, the method 
of its removal being dependent upon the conditions present 
(adhesions from gastric ulcers, pericystitis felleas with perfo- 
ration, fistula, etc.). The removal is best accomplished by 
raising the side of the right lobe and separating all the at- 
tachments, as far as the middle of the spine, so that the lobe 
may be laid over the edges of the ribs of the same side ; the 
left lobe is then to be raised and the remaining attachments 
separated. In so doing it is not necessary to exercise great 
care, as there are no important organs here which have not 
been already examined. If there are very extensive abnor- 
mal adhesions between the liver and diaphragm, the latter is 
also to be removed at the same time, and it is always well to 
do this whenever tuberculous or cancerous nodules are sit- 
uated upon the peritoneal covering of the diaphragm, as 
they usually hold a very important relation to the surface of 
the liver. 

(a.) The Gall-Bladder. 

The exterior is first to be examined, and subsequently the 
interior of the gall-bladder. 

1. External Examination. 
(a.) G-eneral Appearances. 

The size (distention) depends essentially upon the quan- 
tity of the contents, and consequently may vary under nor- 



THE GALL-BLADDER. 303 

mal conditions very considerably ; an increase or diminution 
in size may, however, result from pathological causes. En- 
largement arises from an increase in the contents, and is 
therefore due to closure of the cystic duct. A diminution in 
size, which sometimes becomes extreme, may depend upon 
many different causes; as chronic fibrous inflammation with 
contraction, cancerous degeneration (scirrhus), etc. 

The color of the external surface is usually light or dark 
yellow, reddish- or greenish-yellow ; a gray or even white 
color results from thickening of the capsule, or from altera- 
tion of the contents. In the latter case the bladder is en- 
larged, in the former usually diminished in size. Blood-ves- 
sels are generally seen in very small numbers, and are most 
apt to be found at the part where the bladder is in contact 
with the liver. They are more numerous in inflammatory 
affections, especially in those of the serous covering (peri- 
cystitis), and the color is, consequently, more or less red. 

The consistency depends upon the degree of fullness and 
the condition of the walls. The greatest distention occurs 
in closure of the duct ; a tough consistency, in the absence 
of the previous condition, arises from fibrous thickening of 
the walls. 

(5.) Changes in the Serous Covering of the G all-Bladder. 

The changes of the serous coat are mostly of an inflam- 
matory nature. The most frequent forms are chronic, and 
are, in part, simply fibrous, and in part adhesive (pericysti- 
tis chronica fibrosa and adhsesiva). Adhesions between the 
colon and fundus of the gall-bladder, are very commonly 
met with ; they also occur between the fundus and the ab- 
dominal wall, and also other parts. Acute inflammations of 
this coat and the immediate surroundings (excepting in cases 
of general peritoneal affection) proceed from the gall-blad- 
der or the neighboring parts, especially the transverse colon, 
or they occur without any apparent anatomical cause. They 
generally present an ichorous character (pericystitis ichorosa 
or gangrenosa), since they are often associated with per- 
foration either of the intestine or gall-bladder. The peri- 



304 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

cystitis resulting from perforation is usually due to dysen- 
teric processes, or cancer in the colon, to calculi in the gall- 
bladder, which cause ulceration and perforation, or to other 
ulcers in this organ (typhoidal, etc.). All perforations of 
the gall-bladder, however, do not extend from within out- 
wards, but some proceed from without inwards, in conse- 
quence of pericystitis. The direction which the perforation 
has taken may be determined here, as elsewhere, by the 
greater extension of the ulceration upon the mucous mem- 
brane or upon the serous coat. A general peritonitis results 
when perforation takes place from within, before adhesions 
to the neighboring parts have been formed. If adhesions 
between the gall-bladder and colon or abdominal walls have 
arisen before the perforation occurs, of course the pericystitis 
does not extend, but the bile is discharged directly into the 
intestine or externally through a fistula in the abdominal 
walls, as the skin usually becomes perforated in these cases. 

In order to be able to determine accurately the above con- 
ditions, the liver is, of course, not to be previously removed ; 
if it is taken out the affected parts must also be removed in 
connection with it. 

2. Internal Examination. 

(a.) The Contents. 

After the examination of the exterior is completed, the 
gall-bladder is to be opened by a longitudinal incision, in 
order to examine the contents, which normally vary consider- 
ably in quantity, color, and composition. The color is either 
light or dark yellow, reddish-yellow, greenish-yellow, or 
sometimes almost black. The bile is sometimes thick, again 
quite fluid, and always stringy. A large quantity of fluid, 
which is but slightly, or not at all tinged with bile, consti- 
tutes the so-called dropsy of the gall-bladder (from closure 
of the outlet). 

The most common pathological conditions met with are 
concretions (cholelithiasis), which appear either in the form 
of small particles, rendering the contents gruel-like, or as 



THE GALL-BLADDER. 305 

large compact calculi, which may even attain the size of the 
gall-bladder in extreme cases, so that one stone completely 
fills the cavity. The number of stones is often very large. 
When such is the case their size is generally correspondingly 
small. When several are present they are angular, pos- 
sess sharp edges and smooth facets, in consequence of which 
they are enabled to lie in close contact with each other. 
These surfaces are not the result of attrition, as the angu- 
lar shape is due to the fact that the addition of new concre- 
tion can only take place at those points where contiguous 
stones do not lie in contact with each other. The appear- 
ance of the stones varies according to the chemical compo- 
sition. Most calculi are composed of two constituents, pig- 
ment-lime and cholesterine, which occur either alone or vari- 
ously combined. The pigment-lime calculi vary greatly in 
color, from yellowish-brown to black, and are always very 
soft, so that when pure they are liable to be broken while still 
in the bladder. The cholesterine forms, on the other hand, 
are very hard and possess a crystalline structure ; they are 
colorless and translucent, with a radiating appearance on sec- 
tion. If a small piece is examined with a high power, the 
characteristic crystalline plates may be seen arranged eccen- 
trically over one another ; these become of a sea-green color 
upon the addition of iodine and concentrated sulphuric acid. 
The combined forms occur in great number, and the nucleus 
may be pigment-lime surrounded by cholesterine, or the lat- 
ter surrounded by lime ; the two components, either alone or 
mixed with each other, may alternate in layers — and this 
is the usual structure of most (concentric) biliary calculi. 

The gall-stones do not always lie free in the cavity of the 
bladder, but sometimes in small pockets (diverticula) con- 
nected with the wall ; the communication between the diver- 
ticulum and bladder may become closed by inflammation, 
so that the stone appears to lie entirely outside of the blad- 
der. 

Closure of the cystic duct (which must always be slit open 
when not perfectly free) is usually due to gall-stones which 

20 



306 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

become wedged in it ; this condition may, however, be caused 
in other ways, for instance, by pressure from tumors, the con- 
traction of inflammatory false membranes, or even by a sim- 
ple abrupt bend (displacement), which is sometimes observed, 
especially in children. The result is that the bile cannot 
be discharged, and its constituents gradually disappear, till 
finally a watery, slightly stringy fluid fills the cavity (hy- 
drops vesicce fellece). This fluid is not merely that con- 
tained in the bile, but is secreted by the mucous membrane, 
for the distention of the bladder increases in proportion to 
the duration of the stoppage, so that the bladder may be- 
come twice or thrice its normal size. 

(5.) The Walls. 

The examination begins with the surface, which is remark- 
able for its peculiar folds, presenting a honey-combed ap- 
pearance, which disappears when the bladder is distended in 
hydrops. These folds disappear also in chronic fibrous in- 
flammation, such as often appears in cases of cholelithiasis 
of long standing, in carcinoma, etc. 

The most frequent variety of inflammation is the chronic 
fibrous, which is recognized by the white color and firm con- 
sistency of the mucous membrane. The ulcerative form is 
the most important, and sometimes results from gall-stones, 
at other times occurs in certain diseases, in severe cases of 
typhoid fever (diphtheritis),for instance, and is very liable 
to lead to perforation, as has already been stated. The sub- 
mucous tissue may become inflamed after the mucous mem- 
brane has become ulcerated, and should be exposed in such 
cases by a few longitudinal incisions. Inflammation in it is 
usually of a necrotic character ; the tissue is of a yellowish- 
brown color, and saturated with an opaque, grayish-brown 
fluid, so that the whole layer, and consequently the wall, is 
thickened. The connective tissue is often quite rotten and 
easily torn. 

The tumors of the gall-bladder are confined almost wholly 
to the carcinomata. Occasionally the so-called villous cancer 
occurs, which is always accompanied by a dilatation of the 



THE LIVER. 307 

cavity, into which the papillary masses project ; the ends of 
the papillae are sometimes incrusted with biliary deposit, in 
the same way as those in the urinary bladder are coated 
with salts from the urine. 

Scirrhus of the gall-bladder is much more common, and 
is usually connected with a diminution in the size of the cav- 
ity, at least in those cases which are examined. The inte- 
rior of the bladder is then often completely filled with gall- 
stones. The growth almost always extends to the liver and 
peritoneum, and the secondary growth so often predominates 
that the bladder may be easily overlooked, especially as it is 
usually greatly shrunken, like the stomach when similarly 
affected ; it must therefore be closely looked for, especially 
in cases of general scirrhous adhesions between the abdom- 
inal organs. 

(b.) The Portal Fissure and Lymphatic Glands. 

The examination of the porta hepatis follows that of the 
gall-bladder and its duct. That of the bile-ducts and the 
primary branches of the portal vein may now be completed, 
and the portal lymphatic glands are also to be examined, as 
these may not only be diseased (cancerous and cheesy de- 
generation), but may cause secondary trouble in neighbor* 
ing parts by exercising pressure upon them. Intense icterus, 
for instance, is sometimes produced by the mere pressure 
of the portal glands upon the bile-ducts of children affected 
with general cheesy degeneration of the abdominal lymphatic 
glands. 

(c.) The Liver. 

After all the foregoing parts have been examined, atten- 
tion is to be directed to the exterior of the liver. 

1. External Examination. 

(#.) General Appearances, 

The dimensions of the normal liver of an adult, weighing 
from two thousand to three thousand grams, are as follows : 
total width, twenty -five to thirty centimeters, width of right 



308 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

lobe, eighteen to twenty centimeters ; width of left lobe, eight 
to ten centimeters ; height of right lobe, twenty to twenty- 
two centimeters ; height of left lobe, fifteen to sixteen centi- 
meters ; the greatest thickness, six to nine centimeters. 

These normal dimensions are often greatly exceeded in 
various affections. The latter may be arranged in the fol- 
lowing order, according to the enlargement produced by 
them : parenchymatous inflammation, fatty infiltration, and 
amyloid degeneration, cancerous, leucaemia and adenomatous 
affections (Rindfleisch), the latter giving rise to the greatest 
increase in size. A diminution in size is in general less 
common than enlargement ; it occurs to a moderate degree 
as the simple atrophy of old age, and as brown atrophy. In 
so-called cirrhosis (interstitial inflammation), and in syphi- 
litic atrophy it becomes more marked, and finally the extreme 
degrees are reached in acute yellow atrophy, in which affec- 
tion the organ is often less than half the normal size. 

Circumscribed alterations in size are very common, espe- 
cially the atrophy produced by pressure (from lacing, etc.). 
A circumscribed enlargement occurs as a compensatory con- 
dition in connection with limited atrophies, and happens 
most frequently in livers altered by syphilitic disease. 

Congenital deformities of the liver are often met with, the 
most frequent occurring as one or more furrows which extend 
through the convex portion of the right lobe, parallel to the 
long axis of the body (expiratory furrows of Liebermeister). 
The fact that the capsule is everywhere equally thin and 
unaltered, indicates that the affection is congenital. 

The elongation and flattening of the left lobe, which is 
sometimes observed, is also congenital ; a tongue-like shape 
thus arises reaching as far as the spleen, with which it is 
often connected by false membranes. 

All furrows and notches which are covered with a thick- 
ened and whitish capsule depend upon pathological processes. 
The most common of these conditions is a wide furrow of 
varying depth, which extends transversely across the right 
lobe at a short distance from the lower border, and some- 



THE LIVER. 309 

times across a part of the left lobe. This deformity is pro- 
duced by pressing the edges of the ribs inwards, especially 
by tight lacing. In rare cases this furrow may be so deep 
that the greater part of the tissue becomes atrophied, and 
the lower half of the right lobe becomes separated from the 
upper, so that it is possible to fold the two together. Irreg- 
ular furrows and depressions which are usually directed 
towards the suspensory ligament are caused by syphilitic 
affections. Finally, many irregularities in shape, especially 
at the edge, may be caused by interstitial hepatitis, so that 
the liver sometimes has the appearance of a racemose gland. 

Variations in shape very frequently accompany spinal cur- 
vature and the resulting deformity of the whole thorax ; 
they also accompany peritonitis, especially when caused by 
perforations, with the entrance of gas into the abdominal 
cavity. The clinical symptoms (diminution in the area of 
dullness) indicate that the gas is seated between the liver 
and abdominal walls, and in these cases the outer and upper 
surface of the right lobe is flattened, the depression, caused 
by the accumulated gas and exudation, extending to a vary- 
ing distance towards the suspensory ligament. The small 
conical portions of liver which project into an opening in 
the diaphragm (hernia diaphragm atica) have already been 
referred to. 

The color of the surface, like that of all other organs cov- 
ered by a fibrous capsule, depends essentially upon the con- 
dition of the latter. This is normally very thin and trans- 
parent, so that there are a large number of affections of the 
parenchyma which may be recognized by the altered color 
of the surface. In the more extreme degrees of fatty infil- 
tration, the normal brown or reddish-brown color is con- 
verted into a more or less bright-yellow ; in the lesser degrees, 
a few spots only are seen. If the bright yellow is oceasion- 
alty tinged with bile, the presence of jaundice is indicated. 
Very intense yellow spots, with intervening rod patches, 
occur in acute yellow atrophy, while a dark-brown color 
characterizes brown atrophy, etc. 



310 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

Putrefaction produces a dirty, greenish slate color, which 
is also sometimes found, soon after death, in cases of ichor- 
ous peritonitis. It is then frequently confined to the right 
lobe, corresponding to the place where there is the greatest 
collection of exudation or gas, and is often combined with 
the alteration in shape which has been previously referred 
to. Both conditions frequently cease abruptly at those places 
where the peritoneal reflections are attached, the liver be- 
neath being consequently protected. 

Besides the more general alterations in color, or those that 
extend uniformly over a large space, there are others ap- 
pearing as small and defined yellow spots, which are due to 
circumscribed fatty infiltration. These should not be con- 
founded with pale spots, which are less yellow and more 
gray, and are more or less parallel with the ribs ; the latter 
are simply anaemic spots, such as may be easily produced by 
firm pressure with the finger. Circumscribed spots possess- 
ing a purulent color arise from abscesses, or, more rarely, 
from embolism. Small, bluish-black spots, varying from 
the size of a small pea to that of a ten-cent piece, are due 
to venous tumors (cavernous). Superficial cancers, etc., of 
course produce an abnormal color, corresponding to their ap- 
pearance. 

The consistency of the liver compared with that of other 
organs is rather firm, and depressions made with the finger 
are quickly obliterated. It is increased in fatty infiltration, 
but the elasticity is somewhat diminished, so that the de- 
pressions made with the finger become slowly obliterated. 
The amyloid liver is still more firm, and impressions remain 
permanently. In brown atrophy the liver is also dense, but 
less so than in amyloid degeneration or cirrhosis ; in the 
latter affection the consistency is firmer than in any other 
alteration, and the liver frequently creaks when cut through. 

Softening occurs especially in parenchymatous inflamma- 
tion. The organ loses all its elasticity and in the more ad- 
vanced cases is flabby, a condition which is most marked 
in acute atrophy, where it has the consistency of a " dish- 



THE LIVER. 311 

cloth." Fluctuation occurs, though imperfectly, when large 
abscesses or echinococcus cysts are situated near the surface. 

(6.) The Capsule of the Liver. 

The capsule of the liver becomes involved, not only in 
diseases of the liver, but also in those of the general peri- 
toneum ; chronic inflammatory thickening (perihepatitis 
chronica fibrosa), very commonly occurs, and is usually cir- 
cumscribed. The subcapsular lymph vessels may sometimes 
be very easily traced in such cases, and the thickening often 
becomes first visible within their walls, as is the case with 
the lungs. Adhesive perihepatitis may cause adhesion of the 
liver to the diaphragm, stomach, intestine, spleen, etc. In 
purulent peritonitis a large collection of pus is usually found 
over and about the right lobe. Tubercles and carcinoma 
not unfrequently occur, but the former are less common here 
than in the parenchyma, in which they may often be seen 
through the capsule. 

2. The Interior of the Liver. 

In order to examine the interior of the liver, a single long 
incision usually suffices, extending transversely across and 
entirely through the left and right lobes. If circumscribed 
affections are suspected, or if such are seen upon the surface, 
the number of incisions can be increased at pleasure, but 
they ought always to be made in the same direction, other- 
wise the organ will be so hacked as to render the remainder 
of the examination difficult. 

(«.) General Appearances. 

1. The Parenchyyna as a Whole. 

The first thing to be observed is the amount of blood, both 
in the large and small vessels, upon which the color of the 
parenchyma mostly depends. 

It is very easy to distinguish between the branches of the 
two venous systems of the liver, which alone, are specially 
important in this connection. The walls of the hepatic 



312 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

veins are extremely thin, and lie in direct contact with the 
parenchyma, to which they are firmly adherent, so that these 
vessels, when cut through, do not collapse, but remain widely 
open. Besides, they always occur alone, i. e., unaccompanied 
by any other large blood-vessels or bile-ducts. The portal 
branches, on the other hand, are always accompanied by gall- 
ducts and branches of the hepatic artery, all of which are 
surrounded by connective tissue (Glisson's capsule), which 
decreases in quantity with the size of the vessels. In conse- 
quence of this arrangement the branches of the portal vein 
never remain open like those of the hepatic. 

In determining the quantity of blood within these vessels, 
it is not sufficient to confine the examination to that which 
flows from the cut surface, but the parenchyma must be 
squeezed in order to see how much more can be forced out. 

The condition of the contents of the vessels will be con- 
sidered hereafter in treating of partial thrombosis (simple or 
cancerous). The blood is usually fluid, and of a very dark 
color ; when frothy, and of a faded red or greenish color, 
putrefaction is indicated, a change which occurs quite early 
in the liver. 

The quantity of blood in the parenchyma varies greatly, 
and is greatest in all those affections where there is an ob- 
struction to the flow of blood through the right heart. It is 
seldom uniformly distributed, and its color is frequently mod- 
ified by the proper color of the liver. This is usually red- 
dish-brown ; a white or grayish- yellow color is always due 
to fat (usually fatty infiltration), an orange-yellow, greenish- 
yellow, or even actual green, to icterus. An excess of gray 
results from an increase in the connective tissue (interstitial, 
fibrous hepatitis), a translucent gray from amyloid degenera- 
tion ; a dark brown is due to a deposit of brown pigment in 
the cells (brown atrophy), and a slaty or even black color 
occurs in melansemia. An opaque, usually grayish-brown, 
color is characteristic of parenchymatous inflammation. Pu- 
trefaction produces in the liver, as in most other organs, a 
dirty red, greenish, or blackish color ; this may also appear 



THE LIVER. 313 

upon the surface in circumscribed spots (three to five cen- 
timeters in width) under ichorous peritoneal exudation, or in 
the parenchyma about the vessels or gall-ducts, thus indi- 
cating that under certain circumstances putrefaction com- 
mences at these points. The color thus arising appears very 
quickly about the vessels in all septic diseases. 

The consistency of the liver is also to be tested in the 
examination of the cut surface, the previous general state- 
ment as to which still applies. A granular feel is usually 
characteristic of cirrhosis, and when less marked, of an ex- 
treme degree of fatty infiltration. The consistency is always 
very considerably diminished by putrefaction, and the tissue 
becomes friable and easily crushed, a condition which is espe- 
cially marked when (in an advanced stage of putrefaction) 
gas has been generated in the parenchyma. 

2. The Lobules. 

After this general consideration, the lobules or acini are 
to be also examined in respect to their size, shape, and color, 
all of which are very important, as nearly all diseases of the 
liver stand in very particular relation to the lobules. 

Their size varies greatly, according to the direction in 
which these oblong angular bodies are cut through. More 
will be stated with regard to their recognition in treating 
of the color. They are from one to two millimeters long and 
about one millimeter in width, though their size is usually 
estimated from their general appearance. Enlargement of 
the lobules, which does not necessarily occur in all enlarge- 
ments of the whole liver or of portions of it, is found without 
any pathological alteration of the component parts, especially 
of the cells, in various forms of hypertrophy or hyperplasia 
(compensatory, simple) ; it is also found in a great number 
of diseases which cause an alteration within the cells (paren- 
chymatous hepatitis, fatty liver, amyloid liver). Diminu- 
tion in size occurs in the various forms of atrophy, the sim- 
ple, brown, fibrous, etc. 

The lobules frequently undergo a sort of alteration in 
shape, owing to the disappearance of the more or loss 



314 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

sharply defined boundary which they usually possess, which 
is especially marked in certain pathological conditions (fatty 
infiltration). Under such circumstances they can no longer 
be distinguished from each other, as happens, for instance, in 
many cases of parenchymatous hepatitis. 

The color is the most important quality which the lobules 
present, and depends upon the normal differences between 
the separate portions of the same, which are essentially due 
to the distribution of the blood. After death, the blood col- 
lects mainly in the hepatic veins and the nearest capillaries, 
so that the central portion of the lobule where the capillaries 
empty into the hepatic vein (vas centrale or intralobulare), 
contains more blood, and is consequently of a darker color 
than the periphery, where the capillaries belong to the por- 
tal system and are empty. The borders of the lobules are 
therefore normally lighter in color, more gray than the cen- 
tre, and this color is most marked at those points where the 
portal veins and connective tissue (Glisson's capsule) lie. 
This normal difference in color is increased in certain patho- 
logical conditions, but at the same time is somewhat modi- 
fied. The central dark color is increased, and becomes ex- 
tremely dark red in passive congestion of the hepatic vein, 
and brown in brown atrophy of the cells ; the yellow, yel- 
lowish-red, or greenish color in jaundice, also appears in the 
centre ; on the other hand, the bright grayish-yellow, or pure 
yellow of varying width at the periphery, arises from fatty 
infiltration, while a wide gray or grayish-white zone at the 
periphery, or perhaps more correctly speaking, between the 
lobules, points to an increase of the connective tissue (in- 
terstitial fibrous hepatitis). Tubercles frequently appear as 
small gray specks on the borders of the lobules. Finally, a 
slaty discoloration is found, especially at the periphery, which 
is due to a deposition of black pigment (melansemia). The 
translucent gray color of amyloid degeneration, which also 
possess a dull, waxy lustre, belongs rather to the inter- 
mediate zone, at least in mild cases. 

The microscopic examination of the liver is generally 



THE LIVER. 315 

quite simple, as ordinary needle preparations, in which the 
changes in the hepatic cells can be readily recognized, are 
quite sufficient for the diagnosis of many affections. For 
further examination sections are necessary ; these are made 
with a razor in the same manner as in the kidney, or with 
the double knife, which is still simpler. As a detailed de- 
scription of the pathological conditions occurring in the liver 
is soon to be given, it is merely necessary to mention here 
briefly certain normal appearances which seem to character- 
ize the lobules, and are of great importance in the examina- 
tion of pathological changes. The distinction between the 
hepatic (intralobular) and the portal (interlobular) vein is 
of prime importance, and the points to be considered in the 
microscopical examination are the same as those already re- 
ferred to in describing the gross appearances. The hepatic 
veins are recognized by their very thin walls, which are 
firmly attached to the parenchyma, and by the consequent 
patency of the canal ; they are always surrounded by capil- 
laries and never accompanied by another large vessel, either 
artery, gall-duct, or portal vein. The branches of the portal 
vein, on the other hand, run along the edges of the lobules 
(therefore interlobular), and are surrounded by a certain 
quantit} r of fibrous tissue, which permits their collapse. They 
are, moreover, always accompanied by other vessels, usually 
branches of the hepatic artery, and gall-ducts, which are also 
enclosed in Glisson's capsule. A knowledge of this distinc- 
tion is all the more important in the examination of the 
human liver, as the division into lobules depends wholly 
upon the peculiar course of the vessels, and they are not en- 
tirely separated from each other by connective tissue, as is 
the case in swine. It is still more important in those 
places where Glisson's capsule and the portal vessels are not 
present, and adjoining acini are directly continuous. The 
recognition of the separate lobules is necessary in examining 
the condition of the liver, because different diseases produce 
changes in different portions of them. Another difficulty 
arises, in addition to the one just stated, from the fact that 



316 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

differences in color, which are so important in relation to the 
gross distinction of the different parts of the lobule, become 
of less value the higher the power used, and in every section 
there are contiguous lobules cut through in all possible direc- 
tions (transverse, longitudinal, and oblique). 

In describing the changes which may occur, it has always 
been customary, for the sake of simplicity, to consider them 
with reference to a transverse section of the lobule, and the 
same course will be pursued here. 

( 5.) Special Morbid Conditions, 

1. Atrophy is first to be mentioned among the special 
affections of the liver. The simplest form of destruction of 
the liver substance is atrophy from pressure, which may be 
the result of pressure from without (from lacing, for in- 
stance), or from within (contraction of fibrous tissue). In 
the atrophied portions a part of the cells have wholly disap- 
peared, and only a small mass of connective tissue remains 
instead of the substance of the liver. 

Atrophy of the whole organ occurs in connection with 
general atrophy in cachectic individuals, and also as a change 
belonging to old age. It further occurs in a form which is 
characterized by an atrophy of the whole organ and of the 
separate acini, and also by a deep brown color of the paren- 
chyma ( brown atrophy, atrophia fused). The color is pro- 
duced by brownish, angular granules of pigment which occur 
in the cells, especially of the central zone. These livers are 
always of a very firm consistency, and are therefore particu- 
larly suited for the making of sections for microscopic exam- 
ination ; and all the more so as the lobules are very easily 
seen, owing to their small size, and the fact that they are 
very sharply defined. 

There is another (rare) form of pigment-atrophy, the mel- 
ancemic atrophy, which follows an enlargement of the organ. 
It is characterized by a slaty, blackish, or chocolate color, 
which is frequently distinct only at the periphery of the lob- 
ules, and is due to the deposition of specks of black pigment 



THE LIVER. 317 

in the canal of the capillaries and even larger branches of 
the portal vein, and in the surrounding tissue. This change 
only occurs in severe intermittent fever, in connection with 
similar pigmentation of the spleen. 

Still another form of atrophy is recognized by the dark red 
color of the centre of the lobule (the red atrophy of Vir- 
chow, cyanotic atrophy). It depends upon a marked dilata- 
tion of the hepatic veins and the central portion of the capil- 
lary network, which in turn causes an atrophy of the liver- 
cells lying within it. These cells constantly decrease in size 
and take up more pigment, so that both they and the vessels 
unite in forming the central dark, reddish-brown color. As 
the atrophy of the cells is secondary to the distention of the 
capillaries, the liver does not appear diminished in size, in 
the early stage of the affection, but, on the other hand, is 
enlarged (liver of passive congestion), as is the case in many 
kinds of atrophy of this organ. 

Cyanotic atrophy is neither always uniform in all parts of 
the parenchyma, nor does it always affect large portions, but 
is often limited to small regions, where it may finally involve 
whole acini, so that dark, reddish-brown atrophic streaks are 
produced ; and when they reach the surface, small furrows 
with slight thickening of the capsule may result. The so- 
called yellow atrophy will be considered in connection with 
parenchymatous hepatitis, and cirrhosis (granular atrophy) 
with interstitial hepatitis. 

2. Hypertrophy of the liver, when due to an increase of its 
active, homologous substance, is either general or partial. 
The term does not necessarily imply an increase of the en- 
tire liver, nor of single acini, nor even of single cells, but all 
these conditions are to be discriminated, namely, simple hy- 
pertrophy (enlargement of the cells), simple hyperplasia 
(an increase in the number of cells within the lobules), and 
hyperplasia of the acini. General hypertrophy occurs in 
many infective diseases, sometimes in leucaemia and pseu- 
doleukemia, in diabetes mellitus ; in the latter the cells pre- 
sent a wine-red color when treated with iodine (^glycogen). 



318 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

The partial hypertrophies are more interesting, and are ob- 
served as vicarious or compensatory conditions when a por- 
tion of the liver is destroyed (often very distinct in the left 
lobe in cases of syphilis). Partial hypertrophy occurs some- 
times also in the form of nodules, varying from the size of 
a pea to that of a cherry, which are scattered in numbers 
throughout the liver, and are characterized by the size of 
their acini, and by their frequent pale red color as compared 
with that of the surrounding tissue. 

Besides these true forms of hypertrophy, there are other 
changes which usually cause an enlargement of the whole 
liver and especially of the individual cells, not however by 
the presence of a homologous but of a heterologous material. 
These are the following. 

3. Fatty infiltration, which occurs normally but tempora- 
rily in digestion, is met with as a permanent pathological 
change in various cachectic conditions (phthisis, atrophy of 
children, etc.), and in chronic alcoholism. The lowest de- 
gree of the affection is met with very often as a small, pale, 
not yet distinctly yellow, but rather grayish-white border at 
the periphery of the lobule. As the affection becomes ad- 
vanced this border is wider and more yellow, while the dark 
central portion is correspondingly smaller, till finally, when 
the highest degree is reached (the true fatty liver, hepar 
adiposum, Strasburg goose liver), the whole acinus assumes 
a yellow color resembling that of butter, as, of course, the 
whole parenchyma does ; a pure yellow is present only when 
the liver is anaainic. When it contains blood, a reddish tint 
appears, and when it is congested the red may so predom- 
inate over the yellow that very close inspection is necessary 
lest the fatty condition be overlooked. The diagnosis is 
aided in such cases by the condition of the surface of the 
knife used in making the section of the liver ; this becomes 
smeared with a layer of fat, so that water poured upon it 
flows off and has no tendency to remain. 

This affection is due to the reception of fat in the hepatic 
cells, at first in those at the periphery, and later in those sit- 



THE LIVER. 319 

uated in the central portion of the lobule. The size of the 
cells becomes consequently greater, and thus an increasing 
enlargement of the lobules and the whole organ takes place 
as the affection advances. When the cells are isolated by 
teasing a bit of the tissue with needles, the fat contained 
in them may be easily recognized as large and frequently 
single drops ; it is often more difficult to see the body of 
the cell, as the fat drops may be so large that the proto- 
plasm surrounds it in the form of a thin film. The gross 
appearances are exactly reversed in sections, from which very 
satisfactory pictures may be obtained with a low power 
(when the affection is mild) ; the small, closely-packed fat 
drops with dark outline now produce a dark gray, even black 
color in thick sections, in the edge of the lobules, instead of 
the white color seen with the naked eye. 

Instead of taking place at the edges, fatty infiltration may 
occur exceptionally, without any reason for the exception, 
around the central vein ; the yellow color does not then ap- 
pear in the form of rings, but as small spots (on transverse 
sections), which are separated from the gray periphery by 
a small brownish zone. 

Fatty infiltration is very frequently associated with other 
affections which are partly produced by it, many cases of 
icterus, for instance. Icterus of the liver, like brown pigmen- 
tation, first appears in the centre of the acini, and a very 
pretty picture is seen when these bile-colored centres are 
surrounded by yellowish-white rings. When the cells are 
isolated, some of them are seen to be filled with diffused, 
clear yellow coloring matter ; others with irregular, pale or 
dark yellow, yellowish-red or brownish-red granules, and 
rarely with crystalline pigment. In such preparations the 
reaction of biliary coloring matter may be easily obtained in 
the manner described in treating of the kidney. In order 
to complete the subject of jaundice of the liver, it is to be 
mentioned that when the icterus has continued for a lon£ 
time, and with great intensity, a green color replaces the y ol- 
io w, and the so-called icterus viridis is produced. In certain 



320 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

cases, for instance in acute yellow atrophy, to be more accu- 
rately described hereafter, and in cases of complete closure of 
the excretory ducts, the biliary coloring matter is found not 
only in the hepatic cells, but also in the dilated biliary capil- 
laries, which appear in every section as small varicose canals 
filled with olive-green masses, which are often bifurcated. 

The fatty liver is frequently combined with that produced 
by chronic passive congestion, and the central portion of the 
lobules is then colored dark-red by the latter process, while 
as a result of the former the periphery becomes bright yel- 
low ; this combination furnishes a very characteristic appear- 
ance, resembling that of the cut surface of a nutmeg, and hence 
is called nutmeg liver. If the previously described cyano- 
tic atrophy is also present the atrophied nutmeg liver results. 
The combination of fatty infiltration with parenchymatous 
hepatitis (which in its last stages produces the condition of 
fatty degeneration), with interstitial hepatitis (cirrhosis), 
and with amyloid degeneration will be considered when those 
affections are described. 

4. Amyloid degeneration of the liver is next in frequency 
to that of the spleen, and a very marked enlargement of the 
organ sometimes results, even in children. In extreme cases 
the liver is considerably enlarged and very dense, the outlines 
of the lobules are quite indistinct when the cut surface is 
examined, and the parenchyma presents a translucent, glassy 
appearance and peculiar lustre characteristic of amyloid in- 
filtration ; here and there small portions remain unaffected 
by the process, though they are often of a yellow color from 
fatty infiltration. The greater portion of the cut surface 
assumes a deep brown color when iodine is applied. 

If the lobules in such cases are closely examined, it will 
be observed with the naked eye, and still better with the aid 
of the microscope, that the amyloid change is present every- 
where. If, on the other hand, the affection is but slight, the 
degeneration is confined to the middle zone (for purposes of 
description the lobule is divided into three concentric zones) 
while the outer is prone to fatty infiltration, and the central 



THE LIVER. 321 

to the formation of pigment. It is characteristic of the origin 
of amyloid degeneration that the capillaries of the hepatic 
artery unite with the others in this middle zone especially. 
Although the degeneration spreads from the smallest arteries, 
which are always first diseased, it extends in many cases to 
the liver cells, which become converted into irregular vitreous 
clumps. This is very prettily shown by the application of 
methylaniline to sections or teased preparations. 

Mild cases of amyloid degeneration are recognized with 
difficulty by the eye alone, even when iodine has been ap- 
plied, as the brown color produced by iodine may be masked 
by the brown color of the liver. It is well in such cases 
to make as thin and large a section as possible with the 
scalpel, and lay it for a short time in a small saucer contain- 
ing iodine ; the section should then be washed with water, 
and placed upon some white support, where even very small 
quantities of amyloid material cannot be easily overlooked. 

5. Inflammation. The processes thus far considered and 
relating principally to the cells, have nothing to do with in- 
flammatory changes. There is, however, one alteration of the 
cells which, at least according to the definition of Virchow, is 
to be considered inflammatory, and is consequently called : — 

(a.) Parenchymatous hepatitis. This affection, like paren- 
chymatous inflammation elsewhere, has two stages, the one 
of cloudy swelling of the cells, and the other of fatty degen- 
eration. The latter stage is quite rare in the liver, and is 
generally limited to certain definite forms of disease, al- 
though quite common in the kidney. In those diseases 
which are usually accompanied by parenchymatous changes 
(acute infective diseases, acute exanthemata, etc.), the liver 
appears, as a rule, in the condition of cloudy sicelling. This 
is characterized by great flaccidity of the organ, by enlarge- 
ment of the individual lobules and the entire liver, by in- 
distinctness of the acini, and by a comparatively uniform 
opaque gray color of the cut surface, which suggests that the 
latter has been dipped in boiling water (coagulation of the 
albuminates). The recognition of the milder form of paren- 

21 



322 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

chymatous hepatitis is one of the most difficult things in 
pathological anatomy, and long practice is requisite for this 
to be done with a certain degree of sureness. In these cases 
the diagnosis cannot be greatly aided by observing closely 
the details ; but the liver, like the kidneys, is to be looked at 
from a little distance, as the opacity can be thus most easily 
noticed. Much experience is also necessary in order to make 
a microscopical examination of use in the diagnosis, as the 
normal liver cells are very granular, and it is difficult to 
recognize a slight excess of those granules. In the more 
severe forms the appearances are quite characteristic, the 
cells then being opaque, as if spattered with India-ink, the 
nuclei more or less indistinct under the mass of dark gran- 
ules, and the volume of the cell increased. On the addition 
of acetic acid or caustic alkalies the greater part of these 
granules (albuminates) disappear, but fat granules, if pres- 
ent, remain unchanged. 

The more extreme degrees of parenchymatous inflamma- 
tion, where the cloudy swelling results in fatty degeneration, 
occur principally in two affections, in poisoning by phospho- 
rus (also arsenic, etc.), and in acute atrophy of the liver, the 
aetiology of which has never yet been ascertained. In cases 
of phosphorus poisoning the nature of the process is by no 
means universally agreed upon, as an abnormally large, 
bright, yellow liver with icterus, greatly resembling the or- 
dinary jaundiced, fatty liver, is often found; in consequence 
of this resemblance certain authors have maintained that the 
two are identical, and deny the existence of the parenchy- 
matous inflammation. Other authorities (Virchow, Rind- 
fleisch) contend that the essence of the process is a paren- 
chymatous inflammation in which, according to Rindfleisch, 
large fat drops are formed, while according to Virchow both 
fatty degeneration and fatty infiltration occur, and the latter 
may also be due to the phosphorus, which may possibly ren- 
der the cells more capable of retaining fat. At any rate, 
upon microscopic examination, besides the cells containing 
large fat drops, like those seen in fatty infiltration, others are 



THE LIVER. 323 

found beginning to disintegrate, which is usually not the 
case in infiltration. This question might be positively set- 
tled if atrophy of the liver resulted by the absorption of the 
fatty detritus, but death always occurs before this can take 
place, and a well authenticated case of atrophy after phos- 
phorus poisoning has never been observed. 

The characteristic appearances in acute yellow atrophy, on 
the other hand, depend upon this absorption. This affection 
is met with much more frequently in women than in men, 
and particularly during pregnancy and the puerperal state. 
The early stages, which greatly resemble those produced in 
the liver by phosphorus poisoning, are seldom observed, and 
if found their consistency is usually less than that occurring 
in the latter affection, and the liver, instead of being dimin- 
ished, is increased in size (yellow hypertrophy). In ordinary 
typical cases the organ is frequently reduced to half its nor- 
mal size, is flabby and wrinkled, but still rather tough; 
icteric, yellow elevations of varied size project from the outer 
surface of the liver, and still more from the cut surface, and 
are imbedded in a red ground which is often traversed by 
single delicate gray trabecule. Sometimes the yellow and 
at other times the red portion predominates, while in the 
midst a varying number of punctate haemorrhages are seen, 
which also occur in many other places, especially in the 
connective tissue, as is the case also in phosphorus poisoning. 
The microscopic examination can only be very incompletely 
made when the organ is fresh, owing to its soft condition, 
but it shows that the yellow portions are the more nearly 
normal, as they still contain liver cells, which are filled with 
fat drops of varied size ; a large quantity of biliary coloring 
matter is also found, either diffused, granular, or crystalline 
(crystals of bilirubine), likewise bile-capillaries filled with 
olive-green bile, which have already been referred to. In 
the red portions, on the other hand, there is no longer a 
trace of the liver cells to be found, merely a confused mass 
of fibres and granular detritus. At the junction of the red 
and yellow portions the progressive destruction of the liver 



324 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

cells may be followed. The change is greatest in the red 
portions, where the structure of the organ is completely lost 
(red atrophy, Klebs). Sometimes small islets of granula- 
tion tissue (interstitial hepatitis) occur here and there, espe- 
cially at the edge of the lobules in the yellow portion, also 
clusters of epithelial cells, the nature of which is still uncer- 
tain (hyperplasia of the epithelium lining the gall-ducts ?). 
Certain observers have found numerous colonies of micro- 
cocci in the atrophied livers, but as yet they have not been 
able to establish an serological connection between the two. 

When the liver of acute atrophy is exposed to the air for 
some time after its removal, the cut surface and the walls of 
the vessels are usually found coated with a thin, white, frost- 
like layer, which is found upon microscopic examination to 
be composed of crystals of leucine and tyrosine, especially the 
latter. Leucine occurs in the form of spherical crystalline 
masses, which are often arranged in groups ; tyrosine, on 
the other hand, is in the form of acicular crystals arranged 
in sheaves, somewhat resembling crystals of fatty acids, 
though generally larger ; they may be easily distinguished, 
however, as they are not affected by heat, while the latter 
readily liquefy when warmed. 

(b.) There are still a number of inflammatory affections 
in which the cells are altered as a secondary condition. 

First among these are the metastatic (embolic) inflam- 
mations, which are in general rare, but often occur in certain 
affections, as, for instance, endocarditis ulcerosa. The in- 
farctions usually lie just beneath the capsule, are wedge- 
shaped and of a yellow color. The acini are still apparent 
in the recent forms, but as the infarctions become older the 
central lobules disappear and are replaced by a soft, puriform 
mass. This so-called metastatic abscess is always separated 
from the normal surrounding tissue by a zone of somewhat 
enlarged yellow lobules (parenchymatous inflammation). 
Numerous colonies of micrococci are seen in microscopic sec- 
tions, especially after acetic acid, caustic potash, or soda has 
been added, and are situated not only in the larger, interlob- 



THE LIVER. 325 

ular vessel, but fill the capillaries also for a long distance. 
Very few pus corpuscles are present, the greater part of the 
infarction being composed of disintegrated liver cells. 

If sections are made from places which appear to be still 
unchanged, the micrococci will almost always be found on 
thorough examination ; there may be no changes in their 
vicinity, or slight traces of inflammation may be present, 
which become more pronounced, till finally the inflammatory 
alterations are evident to the naked eye. This gradation of 
appearances leads to the conclusion that the micrococci are 
the cause of the disturbances. 

(e.) The interstitial inflammatory affections of the liver 
include : — 

1. Purulent inflammation, which appears in the form of 
abscesses and is of rare occurrence. Two sorts of abscesses, 
the acute and chronic, are to be distinguished ; the latter is 
characterized by the formation of a firm fibrous tissue, in 
addition to the pus, which may not only surround the ab- 
scess (encapsulated abscess), but also extend through it in 
the form of numerous septa. The abscesses may be of trau- 
matic origin (the greater number of which are found in con- 
nection with injuries of the head, and have nothing to do 
with metastasis), or they may arise from the roots of the 
portal vein (in the spleen, stomach, intestine [especially in 
perityphlitis], also from the umbilical vein), or from the 
gall-ducts ; in the latter case the abscesses may be caused by 
inflammation which is continued from the intestine (typhoid 
fever, dysentery), or by the formations of concretions in the 
ducts, or by the entrance of parasites (ascaris). 

The abscesses may cause secondary changes, by an exten- 
sion of the inflammation, both in the portal (pylephlebitis) 
and in the hepatic veins (hepatophlebitis) ; these veins are 
then filled with softened thrombi, of a puriform, or dirty 
grayish-brown appearance, which extend into the larger 
branches, and the thrombi in the hepatic vein may even give 
rise to embolism of the lungs. It is frequently possible to 
see that the suppuration follows the course of the inflamed 



326 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

vessels. Under the microscope the pus corpuscles, especially 
in old infarctions, are found to have become disintegrated. 
These abscesses must not be confounded with suppurating 
echinococcus cysts, in which the presence of membranes or 
hooklets will render the diagnosis certain. 

2. The inflammatory processes which have been thus far 
considered are more or less acute in character. There re- 
mains a very important chronic inflammation to be described, 
namely, chronic interstitial hepatitis. 

The volume of the liver is increased or diminished in this 
affection, according to the stage of the process, as is the case 
in parenchymatous inflammation. It is only accidentally met 
with in its early stages, as it is then not detrimental to life. 
The principal change produced in the liver consists in an 
increase of the interlobular tissue, and the appearance of 
small grayish masses at the periphery of the lobules. The 
consistency of the liver is increased. The cause of this 
change may be seen in microscopic sections to consist of a 
growth of granulation tissue from Glisson's capsule, from 
which small projections extend into the acini. Even in this 
early stage, the disposition of the newly formed tissue to 
become more highly organized may be recognized, for besides 
the round cells there are numbers having a spindle shape. 
All the further changes depend upon this peculiarity. 

In the later stages of chronic interstitial inflammation the 
liver is more or less diminished in size, in rare cases fully 
one half ; its surface is uneven and covered with prominences, 
which vary from the size of a millet-grain to that of a pea 
(granular atrophy), and are usually of a yellow, icteric 
color. At the edge of the liver, especially in front where it 
is sharp, single nodules are frequently found, completely iso- 
lated, as the capsule belonging to the two surfaces comes in 
contact here. Upon section a similar condition of things is 
seen ; numberless islets of parenchyma, from the size of a 
millet-grain to that of a pea, project from the cut surface 
in the form of round masses, which are infiltrated with fat 
and bile (hence the old name cirrhosis from /appos, tawny, 



THE LIVER. 327 

orange-tawny). These are separated by bands of varying 
width, composed of very tough, grayish fibrous tissue, which 
creaks under the knife, and within which little yellow spots 
are scattered about. Sometimes this process produces a 
thrombosis of the portal vein. 

Upon microscopic examination round cells are still found 
in very few places within the tough interstitial tissue, but 
more frequently those of a spindle shape ; the bands are essen- 
tially composed of tough, interlacing connective tissue fibres, 
between which wide vessels are met with, which may be in- 
jected from the hepatic artery or portal vein. The project- 
ing granules consist of fatty infiltrated and icteric liver tis- 
sue. They do not always represent single lobules or groups 
of them, for although the process extends from the inter- 
lobular connective tissue, it does not always follow the 
boundaries of the lobules in its progress, as these do not 
possess a connective tissue capsule ; they are frequently 
composed only of very small portions of acini or groups of 
acini, which are detached by the irregular penetration of the 
granulation tissue into them. 

The most common cause of this form of interstitial hepa- 
titis, which extends uniformly over the whole organ, is usu- 
ally considered to be the intemperate use of alcohol (gin- 
drinker's liver), still this is not necessary; most drunkards 
do not have a cirrhotic but a fatty liver, and many persons 
with cirrhosis are not in the habit of dram-drinking. There 
is another quite different form, in which the formation of 
fibrous tissue is confined to certain regions, so that large 
lobes, and not small granules, are separated by the contrac- 
tion of the fibrous tissue (tabulated liver'). This form is usu- 
ally due to syphilis. The greater part of this fibrous tissue 
usually occurs in the vicinity of the suspensory ligament, and 
fibrous bands extend from this region into the surrounding 
tissue. The variations in shape which it produces in the or- 
gan are sometimes very great. For instance, the right lobe 
may become so atrophied as to be much smaller than the 
left, which then, of course, frequently undergoes compen- 
satory hypertrophy. 



328 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

3. In addition to this pure interstitial syphilitic affection 
of the liver, which of itself can never be diagnosticated as 
due to syphilis, another form occurs, more rarely but still 
rather frequently ; this is manifested by irregular and 
rounded, homogeneous, yellow, tough, and elastic masses 
{gummata), which are imbedded in the fibrous tissue (hep- 
atitis interstitialis gummosa). The structure of these nod- 
ules does not differ essentially from that of the similar for- 
mations in the testis and other places, which have been 
fully described. 

6. The foregoing affections lead to the consideration of 
the tumors of the liver. 

(<2.) Gummata, without interstitial inflammation, are al- 
most never observed in adults, but there are hereditary 
forms, which occur in new-born children, where the inter- 
stitial inflammation at least is less prominent, so that the 
affection has more the character of a true new formation. 
In these cases the gummata are sometimes in the form of 
large, separate tumors. Again, the whole liver, in which the 
lobules are almost indistinguishable, is studded with an end- 
less number of small, pale yellow bodies of irregular shape, 
very minute gummata. 

(5,) Tuberculosis of the liver usually appears in one of 
two forms, either as a disseminated miliary tuberculosis of 
the parenchyma, or as tuberculosis of the gall-ducts. Dis- 
seminated tuberculosis is always secondary, and of very fre- 
quent occurrence ; it is never absent from the liver, after 
even a few organs have become affected by secondary tuber- 
culosis. The tubercles of the liver are among the smallest 
known, and are consequently very liable to be overlooked. 
In order to be perfectly sure of their presence the microscopic 
examination must always be made whenever there is the 
least possibility of tuberculosis of this organ ; it can then 
be seen how many thousands of tubercles would escape 
notice, without the aid of the microscope. The largest ones 
are evident to the naked eye as minute gray granules the 
size of a pin's head. They are situated at the periphery of 



THE LIVER. 329 

the lobules, but the microscope shows that they are not only 
between but also within them, so that a portion of the par- 
enchyma is replaced by the nodules. Some of the nodules 
are situated upon the smallest bile-ducts, and, consequently, 
have a yellowish-green color, which thus renders them more 
readily recognized. In children the tubercles become larger, 
from the size of a millet-grain to that of a pea ; they are 
then composed of an aggregation of minute tubercles. 

Upon microscopic examination the tubercles often present 
the frequently described reticulated structure and giant-cells, 
but both giant- cells and a coarse reticulum are frequently 
absent. 

The second form is chiefly seated within the walls of the 
bile-ducts, not in the small ones between the lobules but in 
the larger tubes. The disintegration of the tubercles leads 
to ulceration of the surface, as in the ureters, and the canal 
is filled with cheesy material and bile, so that a cavity of 
the size of a pea, bean, or even cherry, is seen on section, 
the walls of which are composed of a firm cheesy mass, and 
the contents are pultaceous, stained yellow or green by 
bile. 

Although large tubercular nodules are rare in the liver, it 
is necessary to know that they are occasionally met with 
from the size of a walnut to that of the fist. These are dis- 
tinguished from cancer, which they may greatly resemble in 
form, by their uniformly dry and cheesy character, and the 
entire absence of any milky fluid when squeezed. Isolated 
submiliary nodules are seen with the microscope in the most 
recently affected places, which indicate that these nodules 
also consist of a conglomeration of small tubercles. 

(<?.) The tumor-like lymphomatous growths, which are 
occasionally found in the liver in typhoid fever, and more 
frequently in leuccemia^ are closely allied to tubercles. In 
leucaemia, especially, they may cause a very considerable en- 
largement of the organ. They appear as grayish nodules o( 
varying size, which are wholly composed of granulation cells. 
Even when they are absent in Leucaemia, the liver is usually 



330 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

considerably enlarged ; and the cut surface, after being ex- 
posed to the air, is soon covered with a white film, which is 
composed of crystals of tyrosine. Colorless octahedral crys- 
tals are also found in great numbers, both upon the cut sur- 
face and in the substance of the organ, of the same character 
as those which have been spoken of in connection with the 
spleen. 

(J.) By far the most interesting of the other tumors of 
the liver, are the carcinomata. Both primary and secondary 
forms occur, the latter being further divided into continued 
and true metastatic growths. Primary cancer, which is ex- 
tremely rare, takes its origin, as a rule, from one spot ; a 
large maternal nodule is surrounded by a number of smaller 
accessory growths, and as the latter increase in size they 
gradually become united with the former. Cancers which 
are continued from some other point present a similar ar- 
rangement, and consequently often appear as if primary ; all 
the more so because the new formation in the liver is often 
much more extensive than at its point of origin. On this 
account, before taking it for granted that a tumor is primary 
in the liver, it is necessary to examine carefully the neigh- 
boring organs, especially the gall-bladder, and the primary 
tumor will often be found in them. 

In the case of metastatic cancers there are usually a num- 
ber of isolated tumors present ; they do not stand in the re- 
lation of maternal and filial nodules, but are of uniform size, 
so that no one of them can be looked upon as giving rise to 
the others. They proceed from primary tumors of different 
varieties ; most frequently from cancer of the stomach, also 
from cancer of the uterus, rectum, breast, oesophagus ; in 
fact, metastases from almost all recognized forms of cancer 
have been observed in the liver. Their microscopic structure 
consequently varies, as the cells and often the entire struct- 
ure of the secondary nodules possess the same characteristics 
as those of the primary growth. The metastatic nodules 
arising from cancer of the stomach, uterus, rectum, and ova- 
ries possess, therefore, cylindrical cells ; those arising from 



THE LIVER. 331 

cancer of the oesophagus, cervical portion of the uterus, etc., 
are the so-called cancroids, while those arising from cancer 
of the breast are composed of irregular cancer cells resem- 
bling glandular epithelium. 

Carcinoma of the liver may also be divided into hard can- 
cer, which possesses an abundant stroma Qscirrhus), and the 
soft or medullary forms ; the telangiectatic growth, which 
is a subdivision of the latter, also occurs here. All these, 
especially scirrhns, are liable to undergo central fatty degen- 
eration and atrophy, in consequence of which the superficial 
nodules possess an umbilicated depression corresponding to 
the atrophy caused by the absorption of the fatty detritus 
from the centre. These fatty degenerated nodules present a 
peculiar variegated appearance on section, as yellow streaks 
alternate with medullary or gray ones (the cancer reticulatus 
of Johannes Muller). 

The cancer stroma may be easily demonstrated by brushing 
the alveolar contents from thin sections ; the resemblance is 
thus often seen between the stroma of the smaller nodules, 
and the network of liver capillaries with its minute quantity 
of surrounding fibrous tissue. It has already been proved 
that the growth of a great number of cancers takes place 
within the vessels. 

The cancerous growth sometimes extends from the larger 
nodules into large branches of the hepatic vein ; these then 
become filled with a cancerous thrombus, which may be pro- 
longed into the vena cava. 

(e.) The metastatic sarcomata, melanomata, etc., which 
occasionally occur in the liver, do not differ in any respect 
from similar growths existing elsewhere. The small cavern- 
ous tumors (cavern omata), which are easily recognized bv 
their dark red color and bloody contents, have already been 
spoken of. Occasionally synall cysts lined with ciliated 
epithelium, are found even in large numbers. These are 
supposed to be congenital and due to the cutting off and 
dilatation of portions of the bile-ducts. Cysts formed after 
birth also originate from partial dilatation of the bile-ducts 



332 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

and are characterized by their tough fibrous walls, and by 
their contents ; in the latter are found, at first at least, bile, 
cholesterine, and less frequently, concretions. Both forms 
are always situated directly beneath the capsule. 

7. Parasites of the liver. 

(a.) The most important of these are eehinococei, the 
most common form of which is the eehinococcus unilocularis 
that sometimes occurs alone and again in numbers, the size 
of the cyst varying from that of a small nut to that of a man's 
head. The substance of the liver appears to be arranged in 
concentric layers about the parasite, owing to the compres- 
sion of the lobules, but it is separated by a fibrous tissue cap- 
sule of not more than one millimeter in thickness. This 
capsule is lined with a translucent, gelatinous eehinococcus 
membrane, which is frequently several millimeters in thick- 
ness. The cyst contains a clear, watery fluid, and often a 
varying number of smaller cysts, usually as large as cherries, 
which are either sterile or dotted upon their inner surface 
with very small white points (the same occur in single cysts). 
These points are the scolices, within which, by the aid of 
the microscope, the head provided with suckers and a double 
row of booklets may be seen inverted within a little cyst. 
It is possible in many cases, by slight pressure, to cause the 
head to protrude, so that the typical form of the cestoid, 
composed of head, neck, and C} 7 st, is obtained. This is the 
appearance of living eehinococei. When dead their appear- 
ance varies according to their age. The fluid first disappears 
and then the cyst is filled with a confused mass of membrane, 
which is always the most important guide in making a diag- 
nosis from the gross appearances. Later, fatty degeneration 
follows, which begins at the periphery and finally leads to 
the filling of the cavity with a soft, yellow pulp in which 
remnants of membrane are still to be recognized. The fat 
then becomes absorbed, and lime salts appear in its place, a 
large or small cretaceous nodule being the sole remnant. The 
importance of this mass is indicated by the eehinococcus 
hooklets, which are easily found by means of the microscope. 



THE PANCREAS. 333 

The whole sac may suppurate or become putrid as a result 
of various external causes (trauma, puncture, etc.), in which 
cases also the microscope is to be resorted to in making a 
correct diagnosis. In many cases, either recent or old 
haemorrhages (haamatoidine), pus, fibrous thickening, or cal- 
cification, are found upon the inner surface of the fibrous 
capsule, that is, between it and the actual cyst. 

Another and much rarer form is the eehinococcus multiloc- 
ularis, which appears as a very firm, and rarely prominent 
tumor. This is composed of numerous cysts which are sur- 
rounded by a thick fibrous capsule, and contain a gelatinous 
mass in the form of lamellae, but scolices are not always 
present. According to Virchow these cysts are developed 
within the lymph vessels. 

(b.) A small worm, the pentastomum denticulatum, is occa- 
sionally met with upon the surface of the liver, and deserves 
merely a passing notice. It occurs as a little white cyst, with 
a very tough wall, one millimeter in thickness, flattened upon 
the surface but arched as it extends into the parenchyma ; 
within this is a crumbled calcareous mass in which it is pos- 
sible, after adding hydrochloric acid, to find the chitinous 
shell of the parasite, studded with rows of spines. 

(c.) In closing the subject of parasites in the liver, the 
distoma may be mentioned. This occurs in the bile-ducts 
and usually gives rise to a severe fibrous inflammation. 

9. THE PANCREAS. 

After the removal of the stomach and the displacement 
downward of the transverse colon, the pancreas appears ; 
both the outer surface and the interior are to be examined, 
the latter by making a longitudinal incision through the 
organ. The excretory duct is easily found in making this 
incision, and may then be laid open with the scissors ; it is 
also easity found when the duodenum is examined. 

On account of the slight pathological importance of the 
pancreas, only the most important changes which occur in 
the glandular tissue or the ducts will be considered. 



334 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

(a.) Morbid Conditions of the Parenchyma, 
The normal pancreas like all the salivary glands, possesses 
a coarsely granular appearance, firm consistency, and also a 
light yellow color ; the latter has, however, a faintly reddish 
tinge soon after death, owing to an infiltration with blood- 
coloring matter. 

1. A relatively frequent change in this organ is atrophy, 
which may be so extreme that only a thin band of fibrous 
tissue remains in its place, within which, possibly by the use 
of the microscope, small traces of the normal glandular tissue 
are still to be found here and there. The relatively frequent 
occurrence of atrophy in diabetes mellitus deserves mention. 
An interstitial formation of fat, similar to the fatty infiltra- 
tion of muscle, occurs here, especially in cases where there is 
a general increase of the fatty tissue. This causes an atro- 
phy of the gland substance, which is of a dirty yellowish-red 
color whenever it is still present. 

2. A parenchymatous change similar to that occurring in 
the other abdominal glandular organs, takes place in the 
pancreas (in typhoid fever, etc.). In the earlier stages 
(during the first or second week) it is large, much red- 
dened, and firm ; later, however, it is pale, grayish-yellow, or 
even pure yellow, and very flaccid. In the latter stages the 
gland cells become fatty. Zenker has recently described 
peculiar cases, where sudden death was apparently caused 
by a haemorrhage into the pancreas, which, in certain in- 
stances, had undergone complete fatty degeneration. 

3. Purulent interstitial inflammation seldom occurs, but 
suppuration around the gland is more frequent (proceeding 
from lymphatic glands, peripancreatitis apostematosa). Fi- 
brous interstitial inflammation on the other hand (pancrea- 
titis inter stitialis chronica fibrosa) is quite common in cases 
of hereditary syphilis. Under such circumstances the gland 
loses more or less of its granular structure, its surface being 
smooth and usually of a grayish color, and its consistency so 
firm that it grates under the knife. It has already been 



THE PANCREAS. 335 

mentioned, in speaking of gastric ulcer, that the pancreas 
frequently become adherent to the stomach, thus preventing 
perforation. A circumscribed inflammation is set up in it 
by the extension of the ulcer, so that its contiguous surface 
becomes converted into a smooth fibrous mass. 

4. Among the different variations of tumors which occur 
in the pancreas, are tubercles and gummata, both of which 
are extremely rare, and carcinoma, which is the most com- 
mon. The latter is seldom metastatic, but usually extends 
from neighboring parts, especially the stomach, or is primary. 
The favorite seat of the latter form is in the head, and it is 
very liable to extend from here to the duodenum. The 
epigastric glands then quickly become involved, and the py- 
lorus lies so near that it often requires a very careful exami- 
nation in order to discover the true seat of the growth. Sev- 
eral incisions must therefore be made through the head of 
the pancreas, in order to see if the normal granular structure 
may not still be observed. Most of these cancers belong to 
the scirrhous variety, and their microscopic examination is 
made in the usual manner. 

5. Peculiar congenital malformations sometimes occur here 
in the form of small supplementary spleens inclosed within 
its head, or of isolated portions of the pancreas in the walls 
of the duodenum (supplementary pancreas), and less fre- 
quently in those of the jejunum or stomach. 

6. Amyloid degeneration of the pancreas occurs under the 
usual ^conditions, and affects principally the vessels of the 
interstitial tissue. 

(5.) Morbid Conditions of the Excretory Ducts. 

The most frequent affection of the excretory ducts is the 
formation of cysts. First, those liable to be confounded with 
abscesses, which are small, varying from the size of a millet- 
grain to that of a bean, and are sometimes filled with a 
clear, watery, and at other times yellow and even thick con- 
tents. These are often multiple and arranged in groups, — 
retention cysts of the interlobular ducts which are filled with 



336 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

catarrhal secretion (acne pancreatica). Then the chief ex- 
cretory duct becomes dilated, usually owing to its being 
closed by a tumor, or by the contraction of a cicatrix (ranula 
pancreatica) . This dilatation may involve either the entire 
duct (varicose dilatation), or only that portion lying behind 
the constriction (cystic dilatation). The glandular tissue is 
usually atrophied in such cases. Frequently the dilated duct 
contains small concretions (^pancreatic calculi), which are 
chiefly composed of phosphate and carbonate of lime. 

10. THE CCELIAC GANGLION. 

The examination of the coeliac ganglion follows that of the 
pancreas ; it lies above this organ, around the coeliac axis, and 
upon the aorta, below and in front of the aortic opening in the 
diaphragm. Generally there is but little to see with the naked 
eye; still it is important to notice the condition of the sur- 
rounding fibrous tissue (chronic inflammation), and the color 
of the ganglion, which is brown when there is great pigmen- 
tation of the ganglion cells. According to Rokitansky, it is 
very hyperaemic, and even hemorrhagic at times in typhoid 
fever, cholera, etc. Atrophy of the ganglion accompanies 
chronic inflammation of the fibrous tissue about the neighbor- 
ing supra-renal capsules in certain cases of Addison's disease, 
and has already been referred to in connection with the latter 
affection. It has also been found atrophied in diabetes melli- 
tus. In all cachexias the nerve cells present a considerable 
increase in the brown pigment granules, which they normally 
contain, and the cells are also atrophied, the nuclei disap- 
pear, etc. The pigment is also increased in old age. The 
vessels of the ganglion become affected by amyloid degener- 
ation, but only in extreme cases where the disease is general. 

11. THE MESENTERY. 

The examination of the mesentery is to be made before 
that of the large and small intestine. It varies in thickness, 
according to the amount of fat present, and may become as 
thick as the fingers. It varies greatly in form and length, 



THE MESENTERIC GLANDS. 337 

along the large intestine, where it is not attached through- 
out. In many cases it is even a foot in length, especially 
at the sigmoid flexure, and then readily becomes twisted. 

(a.) Morbid Conditions of the Mesenteric Fibrous Tissue. 

The mesentery, like all the abdominal connective tissue, is 
the seat of hcemorrhage in poisoning with phosphorus, in acute 
atrophy of the liver, etc., and of phlegmonous swelling in 
malignant pustule, etc. One of the commonest affections is 
circumscribed chronic inflammation (mesenteritis), leading 
to the formation of radiating, contractive, cicatricial tissue, 
which occurs in the mesentery of the small, and especially of 
the large intestine. That of the sigmoid flexure is very 
marked in this respect. 

The affections of the peritoneal covering, especially tuber- 
culosis and carcinoma, have already been considered in con- 
nection with the parietal peritoneum, and they are only 
mentioned here to prevent their being confounded with 
small multiple, fatty papillae, which so stud the mesentery 
in some cases, that the latter has a velvety appearance. 
The mesentery is occasionally the seat of larger tumors, 
among which are the fibroma, fibrosarcoma, dermoid and 
vascular tumors (chylangiomd), etc. 

(&.) Morbid Conditions of the Mesenteric Glands. 

The lymph apparatus within the mesentery of the small 
intestine, both vessels and glands, is possessed of great 
interest, as it takes part in nearly all affections of the intes- 
tinal canal. All the inflammatory intestinal diseases may be 
accompanied by swelling and marked redness (hyperaemia) 
of these mesenteric lymph-glands ; these alterations occur 
most frequently in typhoid fever and tuberculosis, where the 
changes in the glands are of a like specific character. The 
typhoid process leads to extreme swelling, which involves 
the glands in succession, beginning with those in the neigh- 
borhood of the ileo-caacal valve (ileo-cazcal chain'). Typhoid 
glands attain the size of pigeons' eggs, are very soft, juicy, 

22 



338 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

sometimes much reddened, and again paler and more grayish, 
so that they present the so-called medullary appearance. The 
enlargement is due to a hyperplasia of the cells, as may be 
easily seen by teasing bits of gland in a one per -cent, solution 
of common salt, and examining them with the microscope ; 
an abnormally large number of multinucleated cells are also 
found, especially large round forms which often contain from 
twelve to fifteen nuclei. Beside these, there are the very 
peculiar cells containing red-blood corpuscles, probably due 
to the continued hyperemia and consequent slight haemor- 
rhages. 

The typhoid process usually causes no other changes than 
the medullary swelling, but still cases occur where larger or 
smaller portions of the glandular parenchyma become of a 
yellow color, and are sometimes in a state of complete soften- 
ing. This partial necrosis of the parenchyma is the result of 
a compression of the blood-vessels by the constantly increas- 
ing number of cells. In microscopic preparations made from 
such parts, i&tty degenerated cells and fat granules (fatty 
detritus) are found. 

In tuberculous affections of the mesenteric glands, the 
manner in which the process advances from the intestine 
towards the root of the mesentery may also be easily seen ; 
it is always the row of glands which is nearest the intes- 
tine that first presents the tubercular eruption or the greatest 
changes. The connection between them and tuberculous 
ulcers of the intestine is very often made apparent by the 
development of tubercles in the walls of the lymph vessels 
(lacteals), which run from the intestine to the affected 
gland, and by chronic inflammation combined with thick- 
ening of their walls. These vessels are sometimes very 
sharply defined, and even distended by yellowish- white con- 
tents — retained chyle, — its flow being obstructed by the 
development of tubercles in the walls. This retention of 
chyle may also occur alone, when, of course, the nodular 
thickening of the walls is not present. 

The tubercles first appear in the cortical portion of the 



THE MESENTERIC GLANDS. 339 

glands, but the medullary portion is not exempt, and as 
they undergo cheesy degeneration, the former in the first 
place, and then the latter, the whole glandular parenchyma 
may become converted into a homogeneous, yellow, cheesy 
mass. The glands are then enlarged, but usually not so 
much so as in typhoid fever, or in the so-called scrofulous 
affection of the glands, which is most frequently found in 
children (tabes mesentericd) , and which is very closely allied 
to tuberculosis (considered by many to be identical). In 
this affection the glands also become cheesy, and at the same 
time much enlarged (in children they become as large as pig- 
eons' eggs, and in adults still larger). The largest nodules 
are formed by the confluence of a number of glands, and are 
frequently seated in the root of the mesentery. They appear 
so firm, homogeneous, and yellow upon section, that Virchow 
has compared the appearance of the surface with the sec- 
tion of a raw potato, the moisture only being absent. This 
cheesy material softens, often assuming* a greenish tinge ; 
that the softening arises in the centre is evinced by the pres- 
ence of a still firm, cheesy capsule, completely surrounding 
the mass. 

This cheesy substance may become calcified, as in the 
lungs and bronchial glands, and the frequently irregular cre- 
tified masses, which replace either a part or the whole of the 
glands, call attention to the processes which they have passed 
through. 

Differing from these affections, which advance from the in- 
testine towards the root of the mesentery, are others which 
first involve the glands situated nearest the root. Among 
these are leuccemia and pseudo-leuccemia (ade'nie of the 
French, malignant lymphosarcoma, Hodgkins' disease), and 
the changes produced in malignant pustule. In these dis- 
eases the glands undergo the same changes as those which 
have been described as occurring in the bronchial and tra- 
cheal glands. 

Carcinoma of the glands is rather rare, and is readily 
recognized by its usual characteristics. In extreme cases 



340 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

of amyloid degeneration the mesenteric, like other lymph 
glands, become involved. This change is recognized by their 
pallor, translucent gray color, firm consistency, and the 
brown color produced by iodine. 

(<?.) Morbid Conditions of the Large Mesenteric Blood- Vessels. 

The contents of the large blood-vessels of the mesentery 
are sometimes liable to changes (thrombosis) which oftener 
originate in the portal vein (in cirrhosis of the liver, etc.), 
than in the intestine (ulcers). Embolism and aneurisms 
rarely occur here ; the latter, when present, are usually seated 
near the point of origin of the primary branches of the supe- 
rior mesenteric artery. 

12. THE INTESTINE. 
(a.) External Examination. 
The large and small intestines are to be examined in con- 
nection, with regard both to their general condition, and, 
especially, to that of the serous coat. 

1. General Appearances. 

The size of the intestinal canal depends upon two condi- 
tions, the quantity of the contents and the degree of contrac- 
tion of the muscular coat. The contents may be either fecal 
matter or gas (meteorism) ; the presence of fluid fsecal mat- 
ter may be recognized by the weight, and the peculiar gur- 
gling produced by raising a coil of intestine. Of course the 
greatest degree of distention occurs when there is a relaxa- 
tion of the muscular fibres in connection with an increase 
of the contents, as is the case, for instance, in cholera, above 
strictures, etc. Paralysis of the muscular coat is always 
present also in acute peritonitis. On the other hand, strong 
contraction of the muscular coat prevents distention from 
the contents, and even lessens the calibre of the intestine, as 
is seen in very recent cases of severe intestinal inflammation, 
in paralysis of the insane (starvation), etc. 

The color of the exterior depends upon the degree of dis- 



THE INTESTINE. 341 

tention, contents, and amount of blood present. Other 
things being equal, the greater the distention, the paler and 
the more grayish- white is the color ; if the faeces are colored 
with bile, the intestine presents a yellowish or brownish 
color, the intensity of which is proportionate to the color of 
the former ; and if much blood is mingled with the contents 
it will be indicated by a faded red color of the walls. This 
color is distinguished from that of hyperemia, which ap- 
pears, for instance, in severe inflammation, stasis, etc., by its 
diffuse, pale character, while in hyperasmia the injected ves- 
sels are always easily recognized. The hyperaemic vessels 
do not, however, always lie near the surface only, but are 
faintly seen in the deeper portions (mucous and submucous 
coats), in cholera, for example, while in other instances the 
hyperaamia is principally confined to the superficial, subse- 
rous vessels. This latter condition indicates that the cause 
of the trouble is local, and exists within the abdominal cav- 
ity (peritonitis). Not only the acute, but also the severe 
chronic inflammations may be frequently recognized by the 
dark color of the outer wall, for instance, in dysentery ; these 
cases are also distinguished by the deep seat of the color 
from those superficial slaty discolorations, which have been 
described elsewhere as the results of chronic peritonitis. 

2. Changes in the Peritoneal Coat. 

The affections of the serous coat of the intestines, which is 
merely a part of the general lining of the abdominal cavity, 
do not differ from those of the peritoneum which have already 
been described. This layer takes a prominent part in all 
general inflammatory, tuberculous, and cancerous processes. 
It may be mentioned, in addition, that in extensive adhesive 
inflammation, for instance, in such as is produced by diffuse 
cancer, all the coils of intestine may be so bound together 
in one large mass, that it is impossible to trace the separate 
ones. It is then necessary, in order to obtain any idea of 
their relations, to make one or more incisions through the 
centre of the mass. 



342 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

The circumscribed changes which result from deep ulcers 
of the mucous membrane are not less important than those 
extending over large areas. Such ulcers occur in typhoid 
fever and tuberculosis. The tuberculous forms, which usually 
run a very chronic course, generally produce changes upon 
the surface, which, when extensive, consist of rounded, cir- 
cumscribed spots, thickening of the peritoneum, of a dark or 
bluish-red color, and an outgrowth of small gray tubercles. 
The peritoneal tubercles offer the strongest proof of the 
nature of the process in the mucous membrane, and extend 
much further in all directions than the other changes. This 
extension always takes place with great regularity, following 
the course of small, gray, branched and arborescent vessels 
(lacteals), which run from the usual seat of the ulcer, op- 
posite the attachment of the mesentery, toward the latter, 
uniting in their course to form larger branches. It has al- 
ready been stated, in speaking of the affections of the mesen- 
tery, that the tubercles, following the course of the lymph 
vessels (lacteals), may extend as far as the mesenteric glands. 
If the tuberculous nodules of the peritoneum are closely ex- 
amined, it cannot be doubted that they originated from a point 
corresponding to the seat of the ulcer, because they are great- 
est in number and size here, and have already become opaque, 
or even cheesy in the centre ; they become smaller, more iso- 
lated, and translucent, that is, younger, the further they are 
situated from this point. In the large intestine, the ulcers do 
not exhibit the same regularity in regard to their seat, but the 
growth of the tubercles takes place in those parts where the 
serous coat is absent, namely, in the fibrous tissue which lies 
in immediate contact with the intestinal wall. The same is 
the case with the newly formed fibrous tissue, the peritonitic 
membranes, which sometimes appear at the seat of tuber- 
culous ulcers ; thus offering an indication that the tubercles 
are formed here secondarily, and become a relatively late 
associate of the ulcer. 

When the ulcers extend very widely and deeply, another 
alteration arises at a point corresponding with the deepest 



THE INTESTINE. 343 

portion of the ulcer ; this is a necrosis of the serous coat, 
which may very readily cause its complete destruction, and 
thus gives rise to a perforation of the intestine. The necrotic 
portion is soft, of a dirty yellow color, and is very rarely 
more than one centimeter in diameter. 

The typhoid process generally runs a much more rapid 
course than the tuberculous affection, and produces much less 
frequent and extensive alterations of the outer surface of the 
intestine, especially those of a circumscribed character, since 
the intestine as a whole, and particularly its vessels, are more 
often involved. The places where the ulcers are situated are 
indicated by a somewhat greater redness ; but in the rare 
instances where they extend very deeply down to the serous 
coat, the latter becomes necrotic and perforation results, as 
in the case just mentioned of the tuberculous process. There 
are no tubercles, however ; while these are always present 
when the ulcer is tuberculous. This means of distinguishing 
the- two is not always a sure guide, since there are excep- 
tional cases of typhoid fever in which small gray nodules 
(typhoid lymphomata) are developed in the serous coat of 
the intestine, as well as in the liver, kidneys, etc. ; the diag- 
nosis might become doubtful were it not that the medullary 
swelling of the mesenteric glands indicates the actual condi- 
tion. 

The changes produced upon the external surface of the 
intestine by strangulation, also proceed from a circumscribed 
region, but still are expanded over a somewhat large extent. 
The surface nearest the point of strangulation, is of a faded 
dark-red or violet color, which is diffused over a much 
greater area above the seat of the stricture than below it, 
but gradually diminishes towards the more distant portions 
of the intestine. If the strangulation has existed for a loner 
time, the intestinal walls become rotten, necrotic, and per- 
foration may have occurred. 

The alterations may finally be mentioned, which oft on 
take place in the coils of intestine which form a part of the 
walls of an encapsulated peritonitic abscess or ichorua cavity. 



344 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

The changes may be limited to a simple thickening of the 
serous coat ; or an ulceration may take place, especially when 
the contents of the cavity are septic, and by constantly 
extending, finally cause perforation. In order to deter- 
mine whether perforation has taken place from within or 
without, the different layers of the intestine are to be closely 
examined. As the ulcer does not extend directly through, 
but usually has a terraced appearance, the layer which is 
last perforated will present the least amount of ulceration ; 
hence, if the perforation has advanced from within, the 
serous coat will be but slightly altered, while if it has taken 
place from without, the peritoneum will be more diseased than 
the muscular and mucous coats, which are last perforated. 

There is but little to state with regard to tumors, which 
are limited to the surface of the intestine. It is well known 
that the appendices epiploicae of the large intestine may be- 
come abnormally enlarged, and thus form actual lipomata. 

The most common congenital alterations are the diver- 
ticulum ilei, and the pouches of the colon resembling diver- 
ticula. The diverticulum of the small intestine is usually 
situated at the beginning of the ileum ; it is sometimes very 
short and narrow, and again as wide as the intestine itself 
and several inches long. The free end is either simply 
rounded, or (less frequently) terminates in two small rounded 
ends. Its mucous membrane is like that in the rest of the 
intestine, and is subject to the same affections. 

The so-called diverticula of the colon never attain a very 
large size, being usually of the size of beans, never larger 
than cherries, and are due to marked projection of the lon- 
gitudinal and transverse folds. 

Congenital abnormal openings (fistulce congenita?) and ob- 
literations of the intestine usually occur in connection with 
other malformations in non-viable monstrosities. 

(b.) Method of Opening the Intestine. 
After the examination of the exterior of the intestine is 
completed, and also that of the vermiform appendage, the 



THE INTESTINE. 345 

small and large intestine are to be removed in continuity. 
This is best done by separating the large intestine from its 
mesentery and the adjoining fibrous tissue, beginning at the 
caecum and keeping close to the wall of the intestine, and 
laying the latter between the thighs of the person. The 
caecum is then to be seized, and the small intestine freed 
from its mesentery, proceeding from below upwards, and 
cutting as near the intestine as possible. This separation is 
accomplished by making the intestine tense with the left 
hand, and holding the knife like a violin-bow, while the 
stretched mesentery is cut through with a sawing motion. 
The edge of the knife must be somewhat turned towards the 
intestine, in order to prevent its following the direction of 
the traction, which would leave small bits of the mesentery 
attached ; these would later prove to be troublesome, when 
the intestine is opened, because they prevent the intestine 
from being straightened. The detachment is to take place 
as far as the duodenum, and as much of the ascending por- 
tion of the latter is to be removed as possible. The intes- 
tines should be laid at the left of the body that they may be 
more conveniently handled ; the upper end is to be seized, 
and they are to be opened from here with the large blunt- 
pointed shears or enterotome. The small intestine is to be 
cut through along the mesenteric attachment (because Pey- 
er's patches, and the possible important affections of them, 
are situated opposite this), and the colon along one of 
the three longitudinal bands, the so-called taaniaa. During 
this operation, which is performed by simply drawing the 
intestine through the firmly held, half-opened enterotome, 
the left cut edge of the intestine is to be held between the 
thumb and forefinger of the left hand, while the remaining 
fingers are separated so that the opened portion may be im- 
mediately spread over them and its contents examined. In 
all cases where it is desired to examine the contents of 
any particular portion (for instance, the upper portion of 
the small intestine for trichinae), they must be collected at 
once. In medico-legal cases, both ends of such a portion 



346 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

ought to be ligated, to prevent any of the contents from 
being lost or mixed with other substances. When the intes- 
tines have been wholly opened the bulk of the contents is to 
be removed by beginning at the rectum, and drawing the 
intestine between the second and third fingers of the left 
hand, which are outspread or approximated as may be neces- 
sary. Those portions which are freed from their contents 
are to be placed directly in a dish or pail containing water, 
to be more thoroughly cleansed, and the upper end of the 
small intestine is to be left hanging over the edge of the ves- 
sel, that it may be easily found when the intestine is more 
closely examined. As soon as it is washed it is to be again 
drawn between the two fingers of the left hand^ but now 
from above downwards with the mucous membrane upper- 
most, in order that the different portions may be accurately 
examined. 

In many cases, another method, used by the butchers, may 
be employed ; it consists in turning the intestines completely 
inside out without opening them, so that the mucous mem- 
brane lies without and the serous coat within. This may be 
easily done by everting a small portion of the upper extrem- 
ity of the small intestine like a cuff, and directing a strong 
stream of water into the groove thus formed. The eversion 
then constantly progresses till finally the mucous surface of 
the whole intestine, or at least of the entire small intestine, 
is turned outwards. 

(c.) The Contents or the Intestine. 
In examining the contents of the intestine, attention is to 
be paid to their general characteristics, and to any abnormal 
admixture. With regard to the former, the quantity, color, 
consistency, and odor are to be noted; of the admixtures, 
there may be those arising from the food, from the individual 
himself, or from parasites. 

1. General Appearances. 
The quantity of the contents depends both upon the 
amount of food taken and that expelled, also upon the quan- 



THE INTESTINE. 347 

tity of exudation from the intestinal walls. If the small in- 
testine contains much partially digested food, it is an indica- 
tion that nourishment has been taken within a short time ; 
copious masses in the large intestine, especially when very 
hard and rounded, forming scybala, indicate sluggish evac- 
uation, constipation, or coprostasis. An abnormally small 
quantity of intestinal contents indicates that but little food 
has been taken ; when the contents are copious and abnor- 
mally liquid, they are due to exudation from the walls ; 
fluid contents in the large intestine, instead of the normal 
pulp in the upper portion, and the firm masses in the lower, 
indicate that diarrhoea existed. 

The color depends essentially upon the quantity of bile 
present ; when the latter is entirely absent (icterus), the 
fasces are gray. When blood is present, the color is light 
or dark red, according to the quantity, or it may even be 
perfectly black, as is also the case when certain drugs, espe- 
cially iron, have been given. Calomel stains the intestinal 
contents dark green. Typhoid stools have a peculiar yellow 
color, resembling pea-soup, and those in cholera are whitish, 
resembling rice-water. 

The consistency varies from a watery condition to a stony 
hardness. Cholera stools are the most liquid (rice-water), 
and typhoid evacuations are pulpy. In very severe consti- 
pation (coprostasis), small round faecal masses of almost 
stony hardness are found in the pouches of the colon. 

The odor depends wholly upon the quantity of faecal mat- 
ter : fresh cholera stools are entirely free from smell ; the 
thin stools of dysentery have a very offensive odor ; those 
in typhoid fever possess but little odor, while the gray stools 
in jaundice have a most offensive stench. 

2. Abnormal Constituents. 

Among the abnormal constituents which arise from indi- 
gestible food, are peculiar round balls of fat, which resemble 
the large balls of casoine found in the stomachs of children : 
when found in adults they represent undigested, and spheri- 



348 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

cally moulded fat. The remains of animal food, undigested 
portions of fruit (seeds, orange peel), etc., may also be 
found. 

The abnormal ingredients arising from the body may be 
either secretions (mucus, especially in the small intestine), 
or desquamated epithelium (for instance, the white flakes 
that give the peculiar appearance to the cholera stools [post- 
mortem]), or strips of mucous membrane, such as are present 
in many forms of dysentery. Finally, fsecal concretions (see 
vermiform appendage), gall-stones, etc., are sometimes 
found. Blood is found in connection with ulcers, especially 
the dysenteric and typhoid forms, and in extreme passive 
congestion, particularly in cirrhosis of the liver. In these 
cases it is often impossible to discover the point at which the 
blood escapes from the vessels, as it usually comes from a 
great number of small ones. It is then intimately mixed 
with the contents, as has been mentioned in connection with 
the stomach, while considerable masses arise when the hem- 
orrhage comes from a large vessel. 

The most interesting of the parasites, on account of their 
bearing upon the life of the individual, are trichince, which 
remain but temporarily in the intestine. They are almost 
wholly confined to the upper part of the small intestine, and 
consequently, when their existence is suspected, the greatest 
care must be exercised in looking for them. Their sexual 
organs become fully developed about eight days after the 
meat containing the trichinas has been eaten, and they then 
begin to discharge their young, which immediately leave the 
intestine and migrate into the muscles. The females (some 
three millimeters in length) may be easily distinguished 
from the smaller males (about one and a half millimeters 
long) not only by their greater size, but by the presence 
of young in them. The breeding period lasts from four to 
five weeks, but solitary individuals have been found in the 
intestine at a still later period. In endeavoring to find 
them, it is sufficient to dilute a drop of the intestinal con- 
tents with a little water, and examine it thoroughly with a 



THE INTESTINE. 849 

low power ; still it is possible, even with the naked eye, to 
recognize them, especially the females, by bearing in mind 
what has already been stated. 

There are three varieties of cestoid parasites: the taenia 
solium, taenia mediocannelata, and the bothryocephalus dis- 
par, all of which usually live in the jejunum. 

The tcenia solium, the most common and smallest of these 
(two to three meters long), originates from the cysticercus 
cellulosae of swine. The head, which is as large as that of a 
pin, is provided with four lateral suckers, and has a protu- 
berance (rostrum) on the top, armed with a row of hooklets. 
When the individuals are old the suckers and rostrum be- 
come black. Next the head is a very narrow neck, about 
one inch in length, composed of joints which can only be 
recognized with the microscope. The joints of the body 
nearest the neck are wider than they are long, about one 
meter from the head they become square, and further along 
the length exceeds the width. The genital opening is situ- 
ated on the alternate sides of the joints, and the uterus has 
from seven to ten lateral branches. Cyst-like, dropsical 
projections are often seen on single joints, especially at the 
point where the genital opening is situated. 

The tcenia mediocannelata may be four meters in length, 
and also has four suckers, but is destitute of the rostrum 
and hooklets, so that the head is plumper in shape. The 
black pigmentation on the heads of old individuals is usually 
very intense. The joints increase at first more rapidly in 
width than in length, but those which are mature are much 
longer than wide ; the genital opening is at the side, a little 
below the middle and is found in alternate joints. Twenty 
to twenty-five branches extend from each side of the uterus. 

The bothryocephalus latus may attain a length of five to 
eight meters. The head is elongated, club-shaped, flattened 
from side to side at right angles with the joints, and has two 
long, grooved suckers without booklets, which are situated 
on the narrowest surfaces. The width of the joints (twenty- 
four millimeters) greatly exceeds their length (three to three 



350 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

and a half millimeters), and the separated sexual openings 
are upon one of the flat sides, while the uterus is a small 
dark body resembling a rosette. Single joints are sometimes 
perforated (fenestrated) owing to the rupture of excessively- 
distended ovaries. In this manner one or even a number of 
contiguous joints may be so completely divided as to give 
them the appearance of being double. 

The commonest of the larger intestinal parasites are the 
lumbricoid worms (ascaris lumbricoides) which belong to the 
class of round worms, and may be easily recognized by their 
resemblance to earth-worms. They live in the middle of 
the small intestine, but frequently appear in the duodenum 
and even in the stomach. 

The class of round worms also includes the oxyuris ver- 
micularis, which inhabits the rectum but sometimes ascends 
higher, rarely as far as the small intestine. It is cylindrical 
in shape, has a narrow neck and a vesicular projection of the 
chitinous covering at the cephalic end. The male is four 
millimeters in length and has a rounded tail, while that of 
the female (whose length is ten millimeters) is long and 
pointed. The females are much more numerous, and owing 
to their size are more readily seen than the males. They 
are most easily discovered by spreading the mucus from the 
large intestine upon a glass slide and examining it by trans- 
mitted light. 

The long thread-worm (trichoceplialus dhpar') which occurs 
in small numbers in the cascum, is another of this class of 
round worms. They are from forty to fifty millimeters long, 
the males being somewhat smaller than the females. The 
anterior portion of the body is thread-like, and usually firmly 
adherent to the intestinal surface; the posterior is about 
one millimeter thick, in the male coiled in the form of a 
spiral and containing the prepuce and penis, while in the 
female this end is comparatively straight. 

The cercomonas intestinalis belongs to the class of infu- 
soria, and may be described as an oblong, oval animalcule 
0.018-0.011 millimeter long, and 0.009-0.011 millimeter 



THE INTESTINE. 351 

wide, rounded at one end and provided with a slender thread- 
like appendage at the other. They are especially found in 
the dejections of typhoid fever and cholera, and frequently 
show active movements. The balantidium coli has also been 
observed, though but a few times. This animalcule is small, 
cylindrical, the anterior extremity egg-shaped, the mouth 
lateral ; it is entirely covered with ciliated epithelium, and 
in its finely granular body is a nucleus and contractile vesi- 
cles. There are still other varieties of infusorial animalcules 
which occasionally occur in the intestinal contents. 

In addition to the animal parasites vegetable organisms are 
always present in the intestine, belonging to the group 
scliistomycetes, which has recently become so important. 
Both the small spherical forms (micrococci), and the rod-like 
forms (bacteria) occur in every drop of the intestinal con- 
tents and in very large numbers, especially in cases of diar- 
rhoea. They are present in extremely large quantities in 
the intestinal contents of those dead from cholera, and are 
found also equally numerous, and apparently possessing the 
same characteristics, for example, in the liquid contents in 
cases of arsenical poisoning. There is only one intestinal 
affection in which the same typical forms constantly occur, 
namely, mycosis intestinalis, which must be considered from 
recent investigations as a form of malignant pustule. The 
parasites appear only in circumscribed portions of the mu- 
cous membrane, which present definite visible alterations. 
These organisms are long narrow rods (bacteridia), which 
unite in forming long, single, motionless threads, that are 
entangled with each other in a very complex manner. Of 
course large colonies of micrococci often occur in addition 
to these, which appear to stand in close genetic relation to 
the rods. The highest powers (immersion) are required 
in examining these micrococci in order to obtain accurate 
results ; still medium powers (Hartnack's No. 7) enable a 
somewhat trained eye to recognize them. With reference to 
distinguishing the rods from the granules, the mistake may be 
again mentioned, which results from considering the trans- 



352 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

verse sections of the rods turned towards the observer, as 
globules which they then resemble. By moving the bodies 
the deception may easily be prevented. 

(d.) The Walls of the Intestine. 

In examining the intestinal walls especial attention is to 
be paid to the villi, folds (valvulse conniventes), solitary and 
agminated follicles (Peyer's patches). 

1. General Characteristics. 

(aS) An increase in the thickness of the whole intestinal 
wall, and also of its separate layers, is frequently observed. 
A thickening of all the coats over a large area is a frequent 
result of general chronic peritonitis ; the same occurs in a 
circumscribed form in the vicinity of chronic ulcers, etc. 
Hypertrophy of the muscular coat accompanies chronic ulcer- 
ating processes, tumors, etc., in a similar manner as in the 
rectum. 

Thickening of the mucous and submucous layers alone, or 
of certain portions of them, is more frequent. The swelling 
is either purely oedematous, when it has a soft, gelatinous 
appearance, or it is caused by an increase in the solid ele- 
ments, producing a more opaque and grayish color. Simple 
swelling is indicated in the small intestine, especially by an 
elongation and thickening of the folds, and by the formation 
of folds where none normally exist (ileum). Swelling of the 
mucous membrane in the lower portion of the ileum may 
be diagnosticated by such folds alone. 

Enlargement of the villi is usually due to an increase in 
their morphological parts, especially of the epithelium in 
catarrh, or to a cellular infiltration of the substance. They 
may be easily recognized with the naked eye, in such cases, as 
small gray bodies, which are movable in various directions, 
while in the normal condition the individual villi can only be 
recognized with difficulty, and their presence can only be in- 
ferred from the general velvety appearance of the surface of 
the mucous membrane. 



THE INTESTINE. 353 

Swelling of the follicles also depends upon an increase in 
the tissue elements. The normal solitary and agminated 
follicles are often just capable of recognition, as small round 
bodies, projecting but slightly, or not at all, above the sur- 
face. When they are distinctly seen at the first glance, 
therefore, it is generally safe to conclude that they are en- 
larged. They attain the size of a pin's head, when swollen, 
or that of a millet-grain (in catarrh, cholera, etc.), or even 
become as large as peas (in typhoid fever). When Peyer's 
patches are enlarged, either the follicles alone are swollen, or 
there exists also a swelling of the interfollicular substance 
(in extreme cases of typhoid fever). Swelling of the inter- 
follicular substance also occurs alone, without that of the fol- 
licles (in simple catarrh), the patches then present a reticu- 
lated appearance (surface reticule*e). This condition also 
occurs in the stage of resolution of typhoid fever, but, ac- 
cording to Virchow's teaching, is often a post-mortem condi- 
tion, due to the rupture of the follicles and the discharge of 
their contents into the intestine. 

(5.) The normal color of the mucous membrane itself is a 
light gray, but is modified at times by the amount of blood 
present, and, again, by the nature of the contents. The dis- 
coloration produced by the latter is more commonly owing 
to the presence of bile or blood, sometimes also to drugs 
which give rise to a black color, as has already been men- 
tioned. The quantity of blood in the walls produces differ- 
ent shades, according as the capillaries (a uniform red color), 
or the branches of the vessels (distinct red lines), or both to- 
gether (uniform dark -red color with distinct red lines) are 
filled. When there is a complete absence of blood, the gray 
color belonging to the mucous membrane appears, a condition 
suggestive of amyloid degeneration, when it is apparently 
not due to general anaemia. 

Preexisting congestions are indicated by a slaty color, 
sometimes confined to the villi, which then appear as little 
movable black points, or to the follicles, within which a 
black point is then visible. The mucous membrane and 

23 



354 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

villi of the small intestine, or the mucous membrane of the 
large intestine, may present this slaty color, while the fol- 
licles appear as very distinct gray bodies. Finally, Peyer's 
patches may be alone pigmented, the follicles or the interfol- 
licular tissue being affected. By careful examination, the 
black discoloration of the mucous membrane, especially in 
the large intestine, is seen to be in the form ol a net-work ; 
the non-pigmented spaces being the glandular openings, as 
may be easily seen by examining horizontal sections, made 
with scissors, under the microscope. A white spotted appear- 
ance of the intestine, especially of the upper portion of the 
jejunum, is produced by the retention of chyle in the villi. 
The connection of these spots with the villi may be shown 
by moving them to and fro ; when they are examined micro- 
scopically, they are often seen to be clubbed at their ends, 
and to contain fat molecules with dark outlines. 

2. Special Morbid Conditions. 

In treating of the separate affections of the intestine the 
alterations proceeding from the vessels will be considered 
first. 

(a.) Haemorrhage may accompany all affections which are 
characterized by a distention of the vessels, whether the 
hyperemia is due to obstruction or to inflammation. The 
circumscribed forms occur more frequently at the edges of 
ulcers, whether the latter are of tuberculous, typhoid, or 
diphtheritic origin. They also result from obstruction of 
the vessels in cases of endocarditis ulcerosa. They then 
occur in connection with embolic abscesses, even actually con- 
tinuous with them, so that the small abscesses are surrounded 
by a hemorrhagic ring. These forms are distinguished from 
the preceding by the presence of the obstructed vessel in 
their centre (particularly well seen when the intestine is 
made tense and observed by transmitted light), the vessel 
giving rise to a decided prominence. The size of the em- 
bolic abscess varies from that of a mere point to that of a 
pea, and they are easily distinguished from other abscesses 



TEE INTESTINE. 355 

by their connection with the vessels. Embolic ulcers result 
from the rupture of these abscesses into the intestine, and 
their origin is diagnosticated from the association with the 
abscesses. When the emboli are benign, abscesses do not 
occur, but the extravasated blood and the embolus become 
converted into a dark-red, hard body, the centre of which is 
often decolorized, the whole resembling a recent phlebolite. 
Such an appearance is often found when the trouble from 
which it arose no longer exists, at least is no longer apparent. 
Very similar alterations occur as the result of small varices 
of the intestinal veins, which may extend over large areas, 
and when filled with thrombi, may be very easily mistaken 
for emboli ; careful examination of the arterial or venous na- 
ture of the affected vessels will determine this point. 

The embolic nodules resulting from malignant endocar- 
ditis may exist by the hundred throughout the entire intes- 
tine, and, like those occurring elsewhere from the same cause, 
contain emboli which are composed of micrococci. These 
may be easily recognized by making as thin sections as possi- 
ble from the inflamed part with the scissors, teasing them 
somewhat, and treating them with acetic acid. The micro- 
cocci will then be often found as large masses filling the 
arteries. 

(5). Inflammation. 1. The appearances of intestinal ca- 
tarrh (enteritis catarrhalis), which is sometimes confined to 
limited portions, and again is general, do not differ essen- 
tially from those of catarrh of the stomach. Simple, acute, 
or purulent catarrh is indicated by a reddening of the mu- 
cous membrane with slight swelling, the secretion of a tough 
vitreous or gelatinous mucus (especially in children), prolifer- 
ation of the epithelium, which causes the villi to appear thick- 
ened and somewhat opaque, and in certain cases by the secre- 
tion of pus. Chronic catarrh is also usually indicated here 
by a slaty discoloration. When it has existed for a very 
long time, the mucous membrane appears thickened, and is 
often smooth, firm, and gray. Proliferating inflammation, 
such as has been described as occurring in the stomach, is 



356 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

less often found here, and then occurs principally in the 
colon (colitis prolifera vel polyposa) ; a circumscribed form 
is found more frequently in the small intestine also, around 
chronic ulcers, especially those of a tuberculous or dysenteric 
origin. 

Another rare form of chronic inflammation of the mucous 
membrane is met with, which, like the proliferating affec- 
tion, attacks the large intestine chiefly, and occurs especially 
in chronic dysentery. The mucous membrane is decidedly 
thickened, and small mucous cysts are often formed in great 
quantity. These are produced by a swelling of the inter- 
tubular tissue, especially near the surface, so that the mouths 
of the tubular glands become constricted or completely 
closed ; a retention of the secretion follows, and finally, cys- 
tic dilatation of the deeper portions of the gland (enteritis 
chronica cystica'). The mucus may be easily pressed from 
those glands which are not completely closed, and the en- 
trance to the little cavity may then be seen with the unaided 
eye. It is difficult to make a microscopic examination of this 
condition in fresh preparations, although the infiltration of 
the mucous membrane with small cells, and the displacement 
and dilatation of individual tubules may be seen in very thin 
sections made with the scissors or double knife. 

2. Deep seated inflammation of the mucous and the sub- 
mucous coats (enteritis phlegmonosa'), is rare here as in the 
stomach, and is confined almost wholly to cases of an infec- 
tive nature. The affections (mycosis intestinalis) allied to 
malignant pustule also occur here, and more frequently than 
in the stomach. They are characterized by marked, circum- 
scribed, phlegmonous swelling of the mucous membrane, 
(around the fungous growths), and by necrotic destruction of 
the surface and the formations of ulcers. The development of 
the typical bacteridia of malignant pustule (in the form of 
the previously described long threads), and also of micrococci, 
is not confined to the surface, but extends into the tissue, 
where masses of these organisms are sometimes very plainly 
seen in the vessels of the submucous layer. 



THE INTESTINE. 357 

Secondary purulent inflammation is met with in the sub- 
mucous tissue, associated with follicular abscesses, and due 
to an extension of the latter into the surrounding parts. 
Extensive submucous suppuration, with detachment of the 
mucous membrane, may thus occur. 

3. Enteritis follicularis. Inflammatory changes in the 
follicles, whether in the solitary, or agminated, or in both to- 
gether, are associated with most inflammations of the mu- 
cous membrane. In many cases the follicles themselves are 
especially altered. They are swollen in simple inflammation, 
often from mere oedema, and are then translucent, like small 
pearls ; more often the swelling is due to an increase in their 
cells, when they are light gray and opaque. They present 
the frequently mentioned slate color in chronic catarrh. 
They become still more swollen in the higher degrees of 
acute inflammation, and are finally converted through sup- 
puration into small abscesses (follicular abscesses). When 
the latter break into the intestine, the follicular ulcers are 
produced. These are evidently small (lenticular), and have 
sinuous edges which are elevated when water is poured into 
the cavity, owing to the fact that perforation takes place 
only at the top of the abscess, without destroying the whole 
covering. 

The suppuration is, of course, not confined to the glands, 
but extends further, especially into the submucous layer, 
so that large areas of mucous membrane are loosened from 
their bed. Neighboring abscesses may unite, thus leaving 
bridges of mucous membrane, under which a probe may 
often be passed for a long distance. These severe forms 
are most common in the large intestine, in so-called follicular 
dysentery. They are then usually combined with the already 
described chronic inflammation of the mucous membrane. 

Besides the above affections, which form a part of the 
changes occurring in dysentery, there is still another to be 
mentioned, namely : — 

4. Diphtheritic inflammation of the intestine. This oc- 
curs either alone or combined with the previous changes, and 



358 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

constitutes the second anatomical form, diphtheritic dysen- 
tery. It is also principally confined to the large intestine, 
although it may extend far into the ileum in extreme cases. 
The anatomical changes are such as have already been de- 
scribed in connection with the rectum, and generally dimin- 
ish in intensity from below upwards. The inflammation 
begins as grayish bran-like spots on the surface of the mu- 
cous membrane, accompanied by marked swelling of the 
mucous and submucous layers, owing to an acute (erysipela- 
tous) oedema. These spots then become united, and the 
subjacent tissue becomes affected (infiltration of the mucous 
membrane) ; superficial necrosis and ulcers follow, and the 
base of the latter becomes in turn diphtheritic, so that by 
the constant extension of the necrosis, the ulcers increase 
both in size and depth, till, finally, in rare cases, the whole 
thickness of the walls is destroyed and perforation results. 
The gray color of the small deposits becomes yellow, or 
greenish-yellow as the infiltration advances, owing to the 
absorption of biliary coloring matter by the necrosed tissue. 

Gangrene of the mucous membrane may result (gangren- 
ous dysentery), when the inflammation is very severe and 
extends rapidly. 

The localization of the diphtheritic process in the colon and 
ileum is more characteristic than even in the rectum. The 
diphtheritic infiltration is situated, almost without exception, 
on the projecting portions, as would be the case if a strong 
caustic had been rubbed over the intestinal surface. These 
portions are the three longitudinal bands (taeniae) of the 
large intestine, and the transverse folds which unite with 
them in forming the boundaries of the pouches ; in the small 
intestine, the parts affected are the transverse folds, and even 
the separate villi. When the process continues for a long 
time the intervening portion, of course, becomes involved, 
but the changes are always more advanced upon the folds 
and ulceration first takes place here, so that the diphthe- 
ritic ulcers of the large intestine have a very peculiar figure. 
They often bound quite regular spaces, or form long broad 



THE INTESTINE. 359 

bands, from which smaller branches proceed (like the map of 
a mountain chain). 

There is another form of intestinal diphtheritis, less com- 
mon than the one just described, where the process is lim- 
ited to the surface of the projecting follicles (diphtheritis 
follicularis). The progress of the affection is similar to 
that of the previous form, and follicular ulcers result, which, 
.however, differ materially from those already described as 
resulting from abscesses. In the latter variety, the whole 
follicle always suppurates before discharging into the intes- 
tine, and an ulcer results; while in the diphtheritic forms 
the process gradually extends inward from the surface, so 
that ulceration may be present, and follicular tissue still 
remain at the base. The ulcer is consequently open and 
not sinuous, and the edges are flat, as the ulceration extends 
not only downwards but also somewhat laterally, and the 
mucous membrane covering the follicle is completely de- 
stroyed. 

The localization of the diphtheritis is not only peculiar in 
detail, but as a whole ; it follows certain fixed rules. It has 
already been mentioned that the changes usually diminish in 
intensity and extent from below upwards ; they are also 
more advanced where faecal matter is most liable to be 
retained, namely, in the caecum, or commencement of the 
colon, and at the various flexures (flexura hepatica, lienalis, 
and iliaca), of the latter. The effect of this factor is so im- 
portant, that the central portion of the transverse colon is 
very frequently found entirely unaltered, or only in the early 
stages of the disease, and even then but slightly affected, 
while a continuous infiltration, and even ulcers, exist at both 
flexures bounding this portion. 

The result of this affection, and the changes undergone 
by the mucous membrane remaining between the ulcers 
and infiltrated portions, have already been considered in 
connection with the same affection of the rectum. It may, 
however, be repeated, that these remaining portions are 
usually much reddened and swollen, even studded with 



360 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

haemorrhages ; that the ulcers constantly increase in width 
and depth, till the greater part of the membrane is de- 
stroyed, and the muscular coat is laid bare over a corre- 
spondingly large area, as may be recognized by the exposure 
of its transverse fibres, which have become in the mean 
time greatly thickened (hypertrophied). A slaty discolor- 
ation of the ulcers and the entire intestine may result from 
the very great hyperemia which exists from the beginning 
of the affection, and from the haemorrhages, so that the ex- 
istence of dysentery may frequently be suspected from the 
external appearances of the intestine. As has already been 
stated, perforation and peritonitis may result from a still fur- 
ther extension of the ulceration. 

Cicatrization of the ulcers may also take place, and rep- 
resents the more favorable result, although its occurrence is 
limited to cases where the process is less violent, and con- 
fined to a small space. Under such circumstances the in- 
testinal surface has a dark slate color, and the mucous mem- 
brane is replaced by numerous, isolated, irregular scars, or 
perhaps studded here and there with clean ulcers which are 
beginning to cicatrize. The muscular coat is more or less 
thickened in these places. 

It has already been stated that diphtheritic inflammation 
seldom extends from the large to the small intestine. When 
it does, it never becomes so intense as in the former; the 
ulcers are usually wanting, and only the infiltration is pres- 
ent, which diminishes in degree the higher it ascends, till, 
finally, only the small bran-like deposits are present. The 
inflammatory reddening and swelling, of course, extend still 
further upwards. 

The description of intestinal diphtheritis has thus far been 
confined to diphtheritic dysentery, but not every diphtheritis 
is therefore dysentery, and, on the other hand, in what is 
clinically considered to be dysentery very different affections, 
diphtheritis (diphtheritic dysentery), follicular ulcers (follic- 
ular dysentery), or even merely catarrh (catarrhal dysen- 
tery), may be present. Diphtheritic changes are also found 



THE INTESTINE. 361 

in cases of simple f cecal accumulation, but then usually only 
at the flexures of the intestine, and not in the rectum ; they 
are also found in cholera, principally in the small intestine, 
in 'puerperal affections, in the small and large intestine, less 
frequently in typhoid fever, variola, and other infective dis- 



The recognition of these different forms is aided by other 
evidence found at the autopsy. Both the diphtheritic and 
follicular changes, when they are limited to the large in- 
testine, are very extensive, and present the characteristic 
localization, are generally due to dysentery. The follicular 
changes occur in other diseases also, as in the small intestine 
in phthisis. 

5. Scrofulous and tuberculous inflammation. These proc- 
esses differ from the dysenteric, in being seated usually, and 
by preference, in the small intestine, though not to the ex- 
clusion of the large intestine. Besides the processes that 
are undoubtedly tuberculous, all those will be considered 
which lead to cheesy degeneration and ulceration of the fol- 
licles ; although the latter do not admit of being directly 
termed tuberculous, and are not considered as such by many 
authors, still they are very closely related to them. Such 
processes were formerly called scrofulous, as they occur espe- 
cially in scrofulous individuals. The follicles, both solitary 
and those included in Peyer's patches, though not all of 
the latter, become swollen (attaining the size of a millet- 
grain or even that of a split pea), cloudy, and gray, then 
perfectly opaque and yellowish in the centre, till finally the 
whole follicle is converted into a yellow, cheesy mass. When 
they are incised, pus does not appear, as in the case of suppu- 
ration of the follicle, but a crumbling, cheesy mass is brought 
to view, which presents, upon microscopic examination, the 
well-known appearances of cheesy material (shrivelled cells 
and fatty detritus). When the alterations are more ad- 
vanced, the mucous membrane covering the follicles is de- 
stroyed, the cheesy material is discharged, and an ulcer 
results, which has a cheesy base, and projecting, cheesy 



362 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

edges (the primary tubercular ulcer of Rokitansky). These 
may unite and form large, irregular, sinuous ulcerations (Rok- 
itansky 's secondary tubercular ulcer). When this stage is 
reached, unequivocal tuberculosis (secondary) appears, which 
is characterized by the development of small gray nodules 
in the base, upon the edges, and in the immediate neigh- 
borhood of the ulcer. By the constant formation of such 
nodules and by cheesy degeneration of the older ones, the 
ulceration extends continuously, both in depth and surface. 
The shape of the ulcers at the outset is round, and is often 
maintained in those of a half-inch in diameter; still, as a 
rule, it becomes oblong, the long diameter being transverse 
to the axis of the intestine. This configuration is due to the 
fact that the development of the tubercles follows the course 
of the lymph-vessels, which extend from the side opposite 
the attachment of the mesentery, where the greater number 
of ulcers are situated, towards this structure. When the 
ulcer has reached its greatest development, it may com- 
pletely encircle the intestine (annular ulcer). Both the 
base and edges are uneven, the latter appearing as if gnawed, 
and gray or yellow tubercles may be occasionally seen ; they 
are also met with when the floor of the ulcer is formed by the 
muscular coat, the different layers of which may be recog- 
nized by the direction of their fibres, the innermost being 
transverse, the outer longitudinal. Recent tubercular nod- 
ules are situated on the peritoneum, which fact has been 
already fully considered. Hyperaemia and also haemorrhages 
are of frequent occurrence, especially at the edges, and the 
mucous membrane in the vicinity is often hypertrophied. 
Large vessels are sometimes, though rarely, eaten into by the 
ulcer. Tubercular ulcers of large size may exceptionally lie 
parallel to the axis of the intestine instead of being trans- 
verse, thus involving a whole Peyer's patch, as is the case in 
typhoid fever. The differential diagnosis is readily made 
from the accurately described characteristics. Recent, or 
cheesy tubercular nodules may be recognized in the base 
and edges, and often at a distance from the ulcer, when sec- 



THE INTESTINE. 363 

tions are made through it with the double knife. The con- 
tractile muscular cells which are situated beneath the ulcer, 
are usually found to have generally undergone fatty degener- 
ation. 

The termination of the ulcers in necrosis and perfora- 
tion of the intestinal walls, has already been spoken of, and 
it remains to be stated that tuberculous ulcers may undoubt- 
edly heal. Transverse cicatrices are occasionally met with, 
which can be attributed to nothing else. Ulcers are often 
found which have become quite narrow and slit-like, owing 
to cicatricial contraction of their base. The normal mucous 
membrane extends over their edges down to the base, and all 
indications of tubercles are absent. The age of the ulcer is 
made evident by the slaty discoloration. 

The cheesy follicles and the tuberculous ulcers are most 
constantly seated just above the ileo-csecal valve, and from 
this point upwards the changes are, as a rule, less in number 
and extent ; still there are many exceptions. The large in- 
testine is less frequently affected than the small, and when 
the latter contains numerous large ulcerations, there are but 
few small ones in the large intestine, especially in the caecum 
and ascending colon. There is another class of cases in 
which the principal changes are situated in the large in- 
testine, where the ulcers are so numerous and large (larger 
than a silver dollar), that they could not exist in the small 
intestine owing to its limited size. 

6. The principal changes in typhoid fever are seated in 
the ileum, hence the name " ileo-typhus " ; in certain cases 
the large intestine is also greatly involved (" colo-typhus "). 

The typhoid changes in the intestine are almost wholly 
limited to the follicles, especially to Peyer's patches, which 
are altered throughout their whole extent, and therein differ 
from the tuberculous affection. 

In recent cases of typhoid fever the changes consist in a 
marked swelling of the solitary follicles and Peyer's patches, 
which is most intense at the ileo-ca^cal valve, and gradually 
or quite suddenly diminishes from this point upwards, till it 



364: DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

finally disappears altogether. The swelling is not confined 
to the follicles of the patches, but involves the interfollicular 
tissue also, so that the whole patch stands out like a flower- 
bed, often two to four millimeters high, while the edges are 
sometimes overhanging like those of a mushroom. The 
swollen solitary follicles may attain the size of a pea, from 
the associated changes in the surrounding tissue. The larger 
rounded swellings, which occur in various places upon the 
intestinal wall, at a greater or less distance from the attach- 
ment of the mesentery, do not arise from solitary follicles, 
but from small patches composed of three to five or more 
follicles. All the swollen portions are of a grayish-red color 
and soft consistency (medullary sivelling). The rest of the 
intestine is, as a rule, of a dark red color, and in a state 
of catarrhal inflammation. The microscopic examination of 
teased preparations reveals large multinucleated cells in these 
swollen follicles similar to those occurring in the mesenteric 
glands. 

At a later stage, instead of the medullary swelling of the 
solitary follicles and patches, yellowish-gray or yellowish- 
brown (stained by biliary coloring matter) necrotic masses, 
sloughs (sphaceli), are seen ; these do not necessarily exist 
throughout the patch, but are frequently confined to a small 
portion. When a section is made through the part, it may 
be seen that the sloughs extend to a varying depth into the 
swollen tissue, and the limits of the typhoid ulcer, which is 
formed by their separation, are controlled by this fact. The 
earliest ulcers appear in the lower portion of the ileum, and 
they, or partially detached sloughs, may be found here, while 
higher up the sloughs are still firmly attached and the recent 
medullary swelling exists. 

The ulcers which arise from solitary follicles, or from small 
patches, are rounded, and do not, for the most part, lie op- 
posite the mesenteric attachment ; those, on the other hand, 
which are due to sloughing of the larger Peyer's patches, are 
oblong, and, unlike the tubercular forms, are parallel to the 
intestine, owing to the fact that the swelling and ulceration 



THE INTESTINE. 365 

do not extend beyond the limits of the patch, except in the 
most severe cases. In the severest cases ulcers occur which 
almost completely surround the intestine, especially just 
above the ileo-caecal valve. 

Serious results sometimes result from the separation of the 
sloughs, namely, perforation, and arterial haemorrhage, which 
act as immediate causes of death, as will be discovered on 
making the post-mortem examination. The seat of the per- 
foration may be found without difficulty before the intestines 
are opened, but care must be exercised in opening them lest 
a perforation be artificially made. Perforations occur when 
the swelling and subsequent sloughing have extended very 
deeply into the intestinal walls. A circumscribed necrosis 
of the peritoneum follows, and this part is finally ruptured 
by some mechanical cause, for instance, by gas, muscular 
contraction, etc. 

Profuse arterial hcemorrhage is due to the extension of 
the sloughing process into the walls of the vessels, and is 
characterized by the large quantity of blood which is found 
in the intestinal canal. It is a difficult matter to find the 
opened vessel. Its discovery may be aided somewhat by 
noticing the upper limit to which the blood extends, as the 
source may be looked for in the neighborhood of this point. 
It is necessary to examine the ulcers very carefully for ad- 
herent coagula, as they frequently indicate the place from 
which the haemorrhage has taken place. In many cases the 
vessels will be sought for in vain. 

In a still later stage the swelling is diminished, the color 
of the swollen portions is more red, the consistency more 
flabby, and the ulcers (having become clean) possess a 
smooth base, which frequently presents muscular fibres, and 
is diminished in size from the progressive extension of the 
edges over it. Recurrences usually take place at this stage, 
and are to be recognized by the acute medullary swelling in 
connection with the old ulcers. When healing takes place 
all traces of the swelling disappear, the ulcers have a smooth 
glistening surface, and the edges are no longer everted. Still 



366 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

a certain amount of slaty discoloration in the surrounding 
tissue indicates the preexisting hyperemia. 

It is scarcely necessary to state that all medullary swell- 
ings do not inevitably end in ulceration, for most of them 
disappear without the occurrence of any slough whatever. 
This is inferred from those cases in which death results from 
some other cause soon after recovery from typhoid fever, 
and no trace of the disease remains, except perhaps a slight 
amount of slaty discoloration around the lowermost Peyer's 
patches. 

In the large intestine the typhoid process is of course lim- 
ited to the solitary follicles, but in other respects it runs the 
same course as in the small intestine. 

(c.) The tumors, of the intestine require but little consid- 
eration. Besides the small polypi, small myomata and lipo- 
mata, the only important forms are the carcinomata, which 
may be primary or secondary. Primary carcinoma is either 
cylindrical-cell cancer (frequently combined with papillary 
growth), scirrhus, or gelatinous cancer. It is usually found in 
the vicinity of the ileo-caacal valve, where it involves the whole 
intestinal wall over a varying extent, and leads to obstruc- 
tion, which can only be partially relieved by ulceration. 
The general characteristics of these tumors have been suffi- 
ciently treated of in connection with cancers of the rectum. 

Secondary carcinoma is very rare, except when it orig- 
inates in the peritoneum, or extends directly from neighbor- 
ing parts. It is situated in the more superficial portion of 
the mucous membrane, either as small nodules, or large 
masses involving even the entire circumference of the intes- 
tine. The surface of the larger growths is usually ulcerated, 
and peculiar plate-shaped forms result, the edges of which 
project far over the surrounding mucous membrane. 

(d.) Amyloid degeneration of the intestinal mucous mem- 
brane remains to be considered. This affection, as a rule, ap- 
pears in the intestine after some of the glandular organs have 
become infiltrated, though in rare cases it may be seated in 
the former at the outset. Some general cause (cachexia) 



THE INTESTINE. 367 

usually exists, but in very rare cases such cause may be 
absent. The more severe forms can be recognized, without 
the aid of reagents or the microscope, by the pale and waxy 
appearance of the mucous membrane, in connection with en- 
largement of the villi ; but it can be diagnosticated with 
absolute certainty only by means of reagents. When a solu- 
tion of iodine containing iodide of potash is applied, the villi 
appear to be the parts first affected ; still the larger vessels 
are already degenerated, as may be easily demonstrated by 
removing them from the mucous tissue, and treating them 
with iodine. Not only the vessels, bat also the epithelium 
and the rest of the tissue of the villi are affected. Even in 
very severe cases, Peyer's patches usually remain unaltered 
and become very conspicuous after the application of iodine, 
owing to the contrast between their bright yellow color and 
that of the surrounding surface. It is desirable to pour a 
little acetic acid upon the portion of the intestine which has 
been treated with iodine to prevent the possible alkaline 
condition from causing a rapid disappearance of the color. 
Both the large and the small intestine may be degenerated ; 
still the latter is more frequently the seat of the change, and 
more extremely diseased. 

Affections of the vermiform appendage are often fatal, 
yet may produce at times such slight alterations as to be 
readily overlooked. The Regulations, therefore, give explicit 
directions that, in every case of peritonitis at least, this part 
of the intestine shall be carefully examined. 

The vermiform appendage, as is well known, is situated in 
the iliac fossa and bound to the brim of the true pelvis by a 
small mesentery. It is very frequently displaced, however, 
owing particularly to the contraction of false membranes or 
to chronic inflammatory cicatrices in the mesentery itself. 
It is then sometimes drawn towards the spine, or the outer 
abdominal walls, and again may be bent upon itself in vari- 
ous ways. When this is the case the mucous membrane 
usually undergoes alterations; it becomes inflamed, the in- 
terior of the appendage is filled with mucus or pus, es- 



368 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

pecially when the opening into the intestine is closed by- 
compression or abrupt bends. By constant accumulation of 
the secretion dilatation may be produced, and when the se- 
cretion (as in the case of the gall-bladder) becomes converted 
into a clear albuminous fluid, the term dropsical dilatation 
(hydrops processus vermiformis) is applied. These displace- 
ments also give rise to the retention of faecal masses, and the 
formation of f cecal concretions, which are usually oblong or 
oval in shape, and possess a brown or brownish-black color. 
The fsecal concretions often act as foreign bodies (cherry- 
stones, etc.) when they become lodged in the appendage, and 
excite inflammation. Ulceration of the contiguous portions 
of the mucous membrane follows, which extends deeper and 
deeper till perforation finally occurs. Perforation may also 
result from the tuberculous or typhoid ulcerations, which are 
very common here on account of the large number of follicles 
in the mucous membrane. The effects of perforation vary 
according to the condition of the neighboring parts. If the 
appendage lies free in the abdominal cavity, a general peri- 
tonitis is immediately produced, and is usually of an ichorous 
character, owing to the escape of faeces ; if, on the other 
hand, it is separated from the general cavity by old adhe- 
sions, a circumscribed ichorous abscess about the appendage 
and csecum (perityphlitis') results, which may extend either 
upward, downward, or forward, into the connective tissue of 
the abdominal walls. Such adhesions do not always prevent 
perforation into the abdominal cavity, because they may be 
destroyed by ulceration and a fatal general peritonitis still 
be produced. 

In other cases the inflammation extends to some vein 
(thrombophlebitis), and may proceed as far as the vena por- 
tse even, and give rise to a fatal pylephlebitis. 

It is scarcely necessary to mention that in the examination 
of the vermiform appendage the greatest care is to be exer- 
cised, lest an artificial opening be made at some point or 
other. 



THE GREAT VESSELS AND LYMPHATIC GLANDS. 369 

13. THE GBEAT VESSELS AND ADJACENT LYMPHATIC 
GLANDS. 

The only organs of the thorax and abdomen left for ex- 
amination are the great vessels and the lymphatic glands 
which lie near them. In order to reach them conveniently 
the mesentery is to be cut off at its root, when the whole 
aorta, and so much of the vena cava as remains after the 
removal of the liver, will be laid bare. 

The changes taking place in the smaller vessels (those 
supplying the extremities) will be here treated of, as well 
as those occurring in their trunks, since the alterations are 
often directly related, and it is frequently necessary to dis- 
sect the branches for some distance beyond the pelvis. 

(a.) the Veins. 

The inferior vena cava and its branches are first to be 
examined in situ by slitting the anterior wall. 

Attention is to be paid to the contents, both in respect to 
quantity (great engorgement owing to an obstructed outflow) 
and especially with reference to their composition. The 
latter stands in very close relation to the condition of the 
walls, so that the two must be considered together. 

The coagulation of blood (thrombosis') may take place, as 
the result of various causes, partly outside the vessels (ma- 
rasmus, compression, etc.), and partly within their walls 
(varicose enlargement, old periphlebitis and phlebitis, etc.). 
The thrombi are found in the small peripheral branches, or 
within the pockets behind the valves of the larger veins 
(valvular thrombosis'), which may constantly increase till the 
thrombus finally extends through the iliac veins and for a 
varying distance into the inferior cava. Thrombi occurring 
during life are distinguished from post-mortem clots by the 
fact that they are lamellated, being usually composed of al- 
ternate gray and red layers, are more fibrinous, and contain 
many more white corpuscles. The color varies according to 
the age of the thrombus, as the dark-red color which it has at 

21 



3T0 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the outset becomes continuously lighter (decoloration) until 
it is reddish-gray ; a brownish-red, yellow, or even orange- 
yellow color results from the frequent presence of hsematoi- 
dine which is gradually formed. An alteration in consistency 
accompanies this change of color, and the clot becomes con- 
stantly dryer and firmer ; finally, the organizing thrombus 
becomes firmly united and adherent to the walls. Bits of 
old thrombi, when torn to pieces under water, present the 
faded and shrivelled stroma of the red blood-corpuscles, 
often appearing as hemispheric crescents ; masses of hsema- 
toidine, often in the form of beautiful crystalline rhombic 
plates, finely granular detritus, and colorless corpuscles are 
also found ; the latter become more numerous at a later 
period, and constantly increasing numbers of spindle-shaped 
cells, vessels, etc., are added. A certain number of hours 
are always necessary that a thrombus may form, and its 
organization, under ordinary circumstances, takes place so 
rapidly that, according to Rindfleisch, vessels are always 
found in them at the end of eight days. 

When a thrombus does not completely fill the vessel 
(obliterating thrombus), but only partly obstructs it (parietal 
thrombus), a progressive shrinkage takes place, till finally 
only a little mass of pigmented fibrous tissue remains. In 
other cases it sometimes becomes harmless by undergoing the 
sinus-like metamorphosis, being transformed into separate, 
projecting, valve-like membranes of fibrous tissue, which are 
frequently in the form of a spiral, and through which, al- 
though very tortuous, the blood may again circulate. 

Small thrombi, especially the valvular forms, may calcify, 
and thus form the common phlebolites, which are round, 
usually more or less yellow, and vary in size from that of a 
millet-grain to that of a pea. 

Thrombi do not possess the same structure throughout, 
but usually a more recent and an older portion may be dis- 
tinguished, the former being situated at the end nearest the 
heart when the thrombus is still advancing. 

When an extending thrombus in the branch of a vessel 



THE VEINS. 371 

reaches the main trunk, it usually proceeds but a short dis- 
tance along the wall of the latter, constantly diminishing in 
size ; when, on the other hand, it is situated in a larger vessel 
and reaches a branch, the latter either becomes gradually 
plugged or its canal is reduced to a very narrow furrow, 
which often exists as such for a long time. In both cases, 
portions of the upper, rounded, and usually pointed end 
of the clot are readily broken off, and become lodged in 
the pulmonary artery. By examining carefully the end of 
the thrombus in such cases it can be determined whether an 
embolus may have been detached. 

In this benign form of thrombosis the walls of the vessel 
are not in the least involved at first, and later they take part 
in the organization only. 

1. The reverse is the case in the second form of thrombo- 
sis, i. e. thrombophlebitis, which depends upon malignant in- 
flammatory processes. This form most frequently originates 
in the uterine veins, from which it extends into the internal 
spermatic, hypogastric, or even into the inferior vena cava. 
The thrombi in this affection do not become firm, but are 
rapidly converted into a soft, reddish-brown, or yellow puri- 
form mass. The walls of the veins become thickened, and, 
especially the internal layers, have a yellow, or greenish- 
yellow appearance, are frequently studded with small haemor- 
rhages, and the nutrient vessels are distended (thrombophle- 
bitis). 

The minute vessels of the adventitia and media, and also 
the haemorrhages, are plainly seen by examining transverse 
sections with the microscope ; all the coats are infiltrated with 
great numbers of pus corpuscles. 

The microscopic examination of the contents shows quan- 
tities of detritus, fat granules, disintegrating colorless cor- 
puscles, and colonies of parasites in the form of micrococci. 
It is very evident that portions may be much more easily 
separated from this soft mass, and carried into the Lungs 
than from the thrombi first spoken of ; also that emboli 
which originate from the former should be much smaller, as 



372 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

they are more easily broken into pieces at every point where 
the vessels branch. 

2. A third form of thrombosis belongs to the tumor forma- 
tions and is due to the growth of cancerous, or more often sar- 
comatous masses, into the interior of veins. This has already 
been treated of in connection with the liver and kidneys. 

3. Besides this acute inflammation of the walls depending 
upon (secondary to) malignant thrombosis, there is a primary- 
acute inflammation (although not of the intima), occurring 
either with or without the formation of thrombi. Small col- 
lections of pus may result, which project like pustules from 
the inner or outer surface, hence, called phlebitis pseudo- 
pustulosa. Inflammation affecting the tissue around a vein 
(peri- and paraphlebitis) may easily extend to its walls, as 
has been stated in speaking of hepatic abscess. 

4. Chronic inflammatory processes which so often affect 
the aorta, are rarely found in the intima of veins ; still scle- 
rotic plates, which usually calcify and do not undergo fatty 
degeneration, are sometimes met with, especially at those 
points where some mechanical influence is brought to bear, 
for instance, over tumors which obstruct the canal. 

5. Varicose dilatations finally remain for consideration. 
They are most often found in the veins of the lower extrem- 
ities, especially below the knees, where they may appear as 
large, bluish projections beneath the skin. These consist 
of tortuous veins with thin walls, which are dilated, first 
upon one side, then upon the other, and it is often diffi- 
cult to display the canal on account of their tortuous, laby- 
rinthine course. The greatest dilatation is always just above 
the valves. It is well known that they are essentially due 
to mechanical causes. 

(b.) THE ARTERIES. 

The aorta and its two great branches, the iliacs, with their 
primary branches, are usually removed unopened for subse- 
quent careful examination. The upper end of the aorta is 
to be seized (it will be found convenient to insert one finger 



THE AORTA. 373 

into the canal), drawn strongly forwards and separated, 
together with the lumbar lymphatic glands, from the spine 
by oblique cuts made from above and the median line, down- 
wards and outwards. When aneurismal dilatations are pres- 
ent, it is necessary, before removing the vessel, to notice 
their relations to the surrounding parts, especially the bones. 
Such a condition is, in general, readily diagnosticated in ad- 
vance, and the aorta is then removed, together with the 
contiguous thoracic or abdominal viscera, in order that their 
relations may be better made out. 

It is well to observe the diameter of the canal before 
opening the vessel, as it can then be best determined. The 
aorta of adults should admit the forefinger, or even the 
thumb, while it is sometimes so narrow as to scarcely ad- 
mit the little finger. The artery should then be opened 
throughout its whole length, along the anterior wall, and 
the incision carried directly into the iliac and hypogastric 
arteries. Attention should be paid to the contents (often 
wanting), diameter of the canal, thickness and elasticity of 
the walls, and the alterations which result from the special 
diseases. 

1. General Characteristics, 

The width increases with age, the average in the adult 
male being, in the ascending portion from seven to eight 
centimeters, in the thoracic portion from six and a half to five 
and a half centimeters, in the abdominal portion from four 
and one half to four centimeters (in the female it is somewhat 
less) ; it is subject to great variations. Circumscribed dila- 
tations may occur, attaining the size of a man's head, and 
others are found which involve the whole length or a large 
portion (thoracic or abdominal aorta), so that it is one third 
or one half larger than normal. On the other hand, it may 
be so narrow, for instance in the female, as hardly to per- 
mit the insertion of the little finger. 

The thickness of the wall is in general proportional to the 
size of the vessel, the average being two millimeters, while 
the thickness of the wall of small aorta? is often scarcely one 



374 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

millimetre. Exceptions occur in dilatations, where a thin- 
ning sometimes takes place despite the enlargement. 

The elasticity usually varies inversely with the size, a 
dilated aorta being always perfectly inelastic, while the elas- 
ticity is increased in those which are narrow. This fact is 
very important in connection with the measurement of the 
length of the vessel after its removal. As an inelastic ves- 
sel does not contract in the least, it appears very long, 
while those which are elastic shrink considerably, and con- 
sequently diminish in length. Another result is that the 
inelastic vessels can be stretched but little, while the elastic 
ones may be stretched like India-rubber, quickly contracting 
afterwards. 

2. Special Morbid Conditions, particularly of the Intima. 

The normal inner surface of the aorta is perfectly smooth 
and uniformly yellow, but may undergo various changes, all 
of which may essentially result from two conditions : first, 
simple retrograde metamorphoses, which occur principally in 
the layers nearest the blood-current ; secondly, the chronic in- 
flammatory processes (commonly called atheromatous) which 
are situated in the deeper layers. 

1. The retrograde metamorphoses include the transfor- 
mation of the intima into a soft, gelatinous material, which 
resembles mucous tissue, even when examined with the 
microscope (gelatinous metamorphosis), and the very com- 
mon fatty degeneration of the cells of the intima. The latter 
produces a white or lemon-yellow color of the surface, ap- 
pearing in the form of spots, streaks, or irregularly reticu- 
lated and striated figures. This change is very often seated 
in the posterior wall of the aorta about the orifices of the 
intercostal arteries, and longitudinal lines also usually appear 
in this region. Sections may be easily made for microscopic 
examination by stretching the aorta over the forefinger, and 
cutting parallel to the surface with a sharp razor, or by 
tearing off thin layers with a small pair of forceps. In such 
preparations, great numbers of large and small fat drops 



THE ARTERIES. 375 

are seen in the centre of the yellow patch, irregularly dis- 
tributed throughout the intima. At the edge, however, and 
in those parts where the change is less advanced, the fat 
granules are fewer, of much more uniform size, and are 
arranged in triangular or stellate groups, which correspond 
with the enlarged and more plump stellate cells of the in- 
tima. Such an object is especially fitted to illustrate the 
differences between fat granules and micrococci. Although 
these fat granules are in general of uniform size, they never 
possess that perfect uniformity belonging to the micrococci, 
and may be made to disappear entirely by boiling the prep- 
aration in equal parts of absolute alcohol and ether, and in 
glacial acetic acid, which is never the case when micrococci 
are similarly treated. 

Simple fatty degeneration of the cells of the intima pro- 
duces merely a slight elevation of the surface, but may re- 
sult in very important secondary changes, through the de- 
tachment and transportation of the endothelium and layers 
of the fatty patch, by the mechanical effect of the blood- 
current. Superficial losses of substance (fatty erosion) thus 
arise, which do not in general materially affect the resistance 
of the aorta. When this change takes place in smaller ves- 
sels, for instance those of the brain and pia mater, which 
is especially the case in drunkards, rupture may result, as 
the blood forces its way among the cells of the media and 
forms a dissecting aneurism, the outer wall of which, together 
with the adventitia, may be subsequently torn through. 

2. The second form, the inflammatory processes, leads to 
greater deformities. At the outset, small, multiple, smooth 
elevations of the surface arise, which often have abrupt 
edges and usually feel very firm (sclerosis). Such thicken- 
ings are frequently found in the arch of the aorta and at 
those points where the lateral branches are given off, which 
localization is perhaps due to some mechanical cause. The 
microscopic examination of vertical sections readily shows 
that the most superficial layers of the intima arc least al- 
tered, while there is quite an accumulation of small cells in 



876 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the deeper layers and a thickening of the fibrous lamellae. 
Fatty degeneration of the cells very quickly follows this 
thickening, and begins in the lowermost layers of the intiina, 
in consequence of which the sclerotic patches present a spot- 
ted, yellow appearance. At a later stage the fatty degenera- 
tion results in a complete disintegration of the tissue, and the 
formation of a cavity filled with a pulpy mass composed of 
fat granules, cholesterine crystals, and detritus. This is the 
atheromatous abscess, which constantly increases in size to- 
wards the cavity of the vessel, till it breaks through at the 
thinnest point. The mass is then washed out by the blood 
current, and an irregular atheromatous ulcer results, resem- 
bling the follicular ulcer of the intestine, which may be easily 
distinguished from the fatty erosion by its depth and over- 
hanging edges. These ulcers necessarily exert an influence 
upon the blood flowing over them, and numbers of thrombi 
are often found (parietal thrombi}, which constantly increase 
in size, and are floated away and give rise to embolism. The 
thrombi which fill up these ulcers may become organized, 
and the latter are then replaced by scars, the origin of 
which is usually indicated by the slaty color. 

Another result of the atheromatous process is the conver- 
sion of the sclerotic and fatty masses into correspondingly 
large calcareous plates, which are usually smooth on the sur- 
face facing the canal of the vessel, and irregular externally ; 
they are thus distinguished from the occasional calcified pari- 
etal thrombi, the entire surface of which is irregular. These 
plates are sometimes of a slaty color, owing to the absorption 
of blood-pigment and the formation of hasmatoidine. When 
the calcification occurs at a part where there is great thick- 
ening, large, irregular, calcified excrescences may result. Each 
of the changes which have heretofore been described may 
occur separately, or, as is usually the case, in conjunction, so 
that the inner surface of the aorta presents an exceedingly 
diversified appearance, and the outside is very uneven and 
misshapen Qendaortitis chronica deformans). In these ex- 
treme degrees of the affection the vessel is always consider- 



THE ARTERIES. 377 

ably dilated and its walls are thickened and deprived of their 
elasticity. 

3. Calcification of the media must not be confounded with 
the calcification in the intima just mentioned. This pro- 
cess does not take place in the aorta, but is often found 
in the arteries supplying the extremities, especially in old 
people. The vessels are converted into long, rigid tubes, 
which often crack under even slight pressure. This change 
is caused by a calcification of the unstriped muscular tissue of 
the media, while the intima may remain relatively intact. 
Its origin in the media may often be directly recognized 
by the annular deposition of the yellowish-white calcareous 
mass. 

It is very evident that arterial walls thus altered must 
greatly obstruct the flow of blood, and the predisposition of 
old people to gangrene (senile) from slight injuries is thus ac- 
counted for. The blood clots which are present in such cases 
are due to secondary venous thrombosis. The arteries take 
part in the origin of still another variety of gangrene, the 
embolic form, in which the clot plugging the vessel is often 
situated at a long distance from the gangrenous part (for 
instance, in the popliteal artery in gangrene of the foot), 
while in the senile form the thrombus extends upwards from 
the seat of the gangrene. 

The collective alterations in any individual case are com- 
posed of those already described, and are to be sought for 
accordingly. Circumscribed dilatations of the vessels, aneu- 
risms, remain to be considered, and also the congenital alter- 
ations of the aorta, to the importance of which Virchow has 
recently called attention. 

4. Dilatations of the arteries (aneurisms) are either lim- 
ited to a small portion of the vessel, or involve large sections, 
and even entire vascular territories (serpentine or cirsoid 
aneurism^). The last, as its name implies, appears as a tor- 
tuous winding of the elongated and widened vessel, and is 
met with in the peripheral arteries (frontal, occipital, etc.), 
and very frequently in the iliacs. The other forms produce 



378 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

either a general dilatation {cylindrical or fusiform), or one 
limited to a part of the wall (sacculated) ; they are most 
commonly found at the arch of the aorta and the adjacent 
portions, though not always confined to these, but extend to 
the branches which are given off from the arch, especially the 
innominate. The direction followed in the growth of the 
aneurismal sac may vary greatly, and neither soft parts nor 
bones can offer any permanent resistance. Great losses of 
substance may take place, both in the sternum and spine, from 
an advancing aneurism. The bone is destroyed by a fibrous 
metamorphosis, as may be easily seen by microscopic exam- 
ination of small bony spiculse removed from the eroded sur- 
face. 

In the majority of cases the whole aneurismal sac is not 
empty, but more or less filled with thrombotic deposits from 
the blood, which are usually very firm and dry, of a pale-red 
color, and, upon section, are evidently composed of layers. 
Microscopic examination shows that the lamellse contain 
fibrine, red and white corpuscles, and also hasmatoidine. 

The early stage of the aneurism is likely to be overlooked, 
as there is only a slight partial dilatation of the walls, whereas 
the fully formed aneurism cannot escape notice. Slight an- 
eurismal dilatations are often found in the ascending portion 
of the aorta, and should always be looked for when this part 
is examined. In searching other places, assistance is obtained 
from the changes taking place in the intima of the dilated 
part, which are similar to those in large aneurisms, and con- 
sist of the sclerotic and atheromatous conditions already de- 
scribed. These are probably of causal importance in the origin 
of the aneurism (by diminishing the elasticity and power of 
resistance of the walls). Circumscribed atrophy of the mus- 
cular coat (chronic fibrous inflammation ?) may be found 
instead of the inflammatory process in the intima, and, like 
the similar affection in the heart, may be looked upon as a 
cause of the dilatation. In all large aneurisms the media 
has almost wholly disappeared, and often the intima also. 
Traumatic injury may be mentioned as an occasional exter- 



THE ARTERIES. 379 

nal cause for the development of aneurisms. Syphilis holds 
a prominent position among the causes which result in the 
endaortitis antecedent to aneurismal dilatation. 

There is a peculiar variety of (false) aneurism, the dissect- 
ing aneurism of the aorta, which consists in a separation of 
the outer from the middle coat by a current of blood, which 
has entered through a rent in the intima and media at the 
upper part of the vessel ; the blood is now forced downwards, 
even as far as the aortic opening in the diaphragm, splitting 
the two coats apart, and then often returns to the interior 
of the aorta through a second rupture of the intima. In 
this form also, atheromatous changes in the intima, or fatty 
degeneration of the media, are probably the cause of the 
rupture. These aneurisms are classified among the so-called 
false aneurisms, as are also those of traumatic origin, in 
which the blood-sac lies wholly outside of the artery, and is 
composed of the surrounding fibrous tissue. The varicose 
aneurism, which is also usually of traumatic origin, and con- 
sists of a sac between an artery and vein communicating 
with each, comes under this head also. 

5. Congenital alterations of the aorta include the rare 
stenosis or atresia which usually results in immediate death, 
and the very important aplasia, or more correctly speaking, 
hypoplasia, which manifests itself in the first place by a 
narrowness of the vessel. Such a hypoplastic aorta in adults 
is often scarcely large enough to admit the little finger, the 
diameter of the thoracic portion being from three to four 
centimeters and that of the abdominal portion from two to 
three centimeters. A thinness of the walls is present, and 
also an increase of the elasticity, so that when the aorta is re- 
moved it shrinks very much and may be stretched out like 
braces. There is also present an irregularity in the origin of 
the intercostal arteries, which are absent at one point, too 
numerous at another, etc., and further, a bright-yellou\ figured 
appearance and ivavy thickening of the intima, especially on 
the posterior wall, along and between the orifices of the 
intercostal arteries. Virchow has demonstrated the eonnec- 



380 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

tion between this hypoplasia of the aorta (observed espe- 
cially in the female), which sometimes occurs with, and 
sometimes without, a similar alteration in the heart, and 
general disease (chlorosis*), also with disease of the heart 
(endo carditis'). 

(c.) THE RETROPERITONEAL LYMPHATIC GLANDS. 

The lumbar lymphatic glands, which are situated about 
the aorta and inferior vena cava, are subject to many changes, 
which do not differ greatly in their nature from those of 
other lymphatic glands, so that it will be sufficient to give 
them a passing notice. 

Swelling results from inflammatory affections of any sort 
situated at the origin of the afferent lymphatic vessels (true 
pelvis, etc.), and especially in syphilis, in which affection 
suppuration, like that observed in the inguinal glands, may 
take place. The lumbar glands also undergo degeneration 
in connection with tumors, especially tumors of the testis, 
though less frequently in consequence of cancer of the uterus, 
etc. They become involved, moreover, in the leuccemic and 
pseudoleuccemie affections (lymphosarcoma), also in malig- 
nant pustule and other similar general diseases. Syphilis 
gives rise to chronic swelling and induration of the glands. 
They undergo amyloid degeneration as a result of the general 
amyloid process, and become cheesy in connection with a sim- 
ilar change in other organs, especially the intestinal and mes- 
enteric glands. Finally, there are a number of primary 
tumors (fibromata, sarcomata, lipomata, carcinomata [?]), 
which originate in part from these lymphatic glands, and in 
part from the surrounding (retroperitoneal) fibrous tissue. 

(d.) THE THORACIC DUCT. 

The examination of the thoracic duct and receptaculum 
chyli, which by the way is seldom necessary, naturally follows 
that of the glands. The receptaculum chyli lies to the right 
and behind the aorta, upon the second or third lumbar ver- 
tebra ; the duct lies behind and to the right of the aorta. 



THE INTERNAL MUSCLES OF THE TRUNK. 381 

The changes to which it is subject are dilatations, either 
throughout its whole length or limited to a small portion, 
and are usually due to pressure. Partial obliteration may 
also be found, and may possibly result from inflammation, 
fresh signs of which have been but very rarely found. The 
duct may sometimes contain bloody fluid or a clot. 

14. THE INTERNAL MUSCLES OF THE TRUNK. 

In order to complete the examination of the thoracic and 
abdominal cavity, the internal muscles and the bones must 
not be omitted. 

(a.) The diaphragm may be first mentioned, although its 
alterations are essentially dependent upon those of its serous 
coverings, which have already been sufficiently treated of. 
There are three conditions, however, yet to be noticed : in 
the first place, the diaphragm is earliest and most affected by 
trichina?, and is therefore always to be examined when their 
presence is suspected. Secondly, the muscular fibres of the 
diaphragm often undergo fatty degeneration (also brown 
atrophy), and then the process is often associated with 
a similar change of the heart. Finally, the diaphragm is 
especially adapted, from its richness in lymph-vessels, to 
illustrate the advance of inflammatory processes along the 
course of the lymphatics. The observation made by Wal- 
deyer is quite characteristic in this respect, namely, that 
in puerperal peritonitis the lymph-vessels were completely 
plugged with micrococci. Actual purulent inflammation 
(diaphragmatitis plilegmonosa) is more rare ; where it occurs 
a marked thickening of the diaphragm is also present. 

6. The muscles belonging to the pelvis are next to be ex- 
amined, the most important of which is the ilio-psoas, from 
its being the very frequent seat of purulent inflammation 
(jpsoas abscess'). This affection is always secondary, some- 
times to trouble in the spine (caries), and again to trouble in 
the pelvis (caries, coxitis), and may be unilateral or bilat- 
eral ; when the latter is the case, affections of the spine must 
always be thought of. The presence of the disturbance 



382 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

may be suspected, even before the muscle is cut into, by the 
greenish color of its surface and by the more or less distinct 
fluctuation. When the abscess is opened it may be found of 
various size, so large even that the muscle itself may be com- 
pletely destroyed, in which case the abscess is surrounded 
only by the thickened perimysium and surrounding connec- 
tive tissue. The walls are usually uneven, ragged (rem- 
nants of muscle), and frequently of a slaty color. The pus, 
especially in case of caries, of the pelvis, contains more or 
less numerous bits of bone, which suggest the admixture of 
sand, and indicate the origin of the trouble. The abscess 
may sometimes be traced into the true pelvis and as far as 
the hip-joint, which may be perforated secondarily and sup- 
purate. On the other hand it may extend upwards for a 
considerable distance, especially when the bones of the upper 
part of the trunk are affected ; still the track is not always 
easily followed, as the seat of the caries is frequently con- 
nected with the abscess only by a very narrow and tortuous 
fistula. Perforation of the descending colon may take place 
from the abscess, and faecal matter may then be discharged 
into the latter ; if the abscess should also discharge through 
the skin an indirect faecal fistula would result. 

Secondary tumors are quite often formed in the ilio-psoas, 
owing to its proximity to numerous organs ; the nature of 
the primary affection determines the composition of such 
secondary growths. 

15. THE FRONT OF THE SPINE. 

(a.) General Characteristics. 

Alterations in shape are among the most noticeable patho- 
logical changes in the vertebral column, and are most marked 
in the dorsal portion. The different varieties are scoliosis, or 
lateral curvature (usually to the right side in the dorsal por- 
tion), kyphosis, or curvature backwards, and lordosis, or cur- 
vature towards the front. Very frequently scoliosis is com- 
bined with one of the other forms, occurring especially as 



THE FRONT OF THE SPINE. 383 

kyphoscoliosis. When a curvature occurs afc any one point 
it is counterbalanced by a curve in another direction else- 
where, — the most common example is this, a kypho-scoliosis 
in the dorsal, counteracted by a lordosis in the lumbar region. 
In case of lateral curvature the vertebrae themselves are 
always turned upon their axis, so that the body is turned 
towards the convexity of the curvature. The bodies of the 
vertebrae are also altered in shape, being shorter on the side 
towards the concavity, as is also the intervertebral substance, 
which may be wholly wanting here, being replaced by a 
synostosis of the vertebrae. Kyphosis may consist in a sim- 
ple or a more or less angular curvature, the latter being due 
to deep-seated local disease of the bone (Pott's disease). 
As the usual cause of angular curvature is caries, which has 
either run its course or still exists, it is always necessary in 
such cases to count the vertebrae in order to see that one or 
even more are not wanting. In order to determine accu- 
rately the number of the bodies of the vertebras which have 
been destroyed, the spinous processes, which usually remain 
intact, are to be counted. In making a careful examination 
it is necessary to remove the affected portion completely, 
and saw through it longitudinally, otherwise pathological 
changes in the bodies of the vertebrae, or intervertebral sub- 
stance, may be easily overlooked. In order to accomplish 
the removal, a high block of wood is to be placed under the 
back, directly beneath the portion to be removed, and, if 
necessary, the corresponding ribs are to be severed with the 
bone-shears. The intervertebral substance which bounds the 
desired portion is then cut through with a cartilage-knife, 
when both the upper and lower portions of the body will 
fall back by their own weighty and the portion to be re- 
moved will be retained only by the lateral joints. It is best 
to cut through these with a chisel, and then a finger, the 
chisel, or something convenient, is to be thrust into the 
spinal canal, and by drawing the piece firmly forwards, the 
muscles lying behind the vertebrae can be separated from 
them. 



384 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

(5.) Special Morbid Conditions. 

Fractures of the spinal column may be transverse or lon- 
gitudinal, and are frequently comminuted or combined with 
a crushing of a portion of the bodies. Both the fractures 
and dislocations, the latter being necessarily partial, are lia- 
ble to produce deformities of the spine, like the carious 
affections, and a longitudinal section is also best adapted for 
their examination. 

The inflammatory processes in the vertebrae usually mani- 
fest themselves as caries, and are included under the name of 
spondylarthrocace. Two forms, however, must be distin- 
guished, the simple carious (purulent) and the cheesy in- 
flammation. The first may occur at any time of life, some- 
times being primary in the vertebrae (at times of traumatic 
origin), and again extending from neighboring abscesses. 
As a rule, a great quantity of pus is formed {prevertebral 
abscess), which by constantly extending into the connective 
tissue of remote parts, especially of the psoas muscle, pro- 
duces a large abscess which may finally discharge outwardly 
(cold abscess). 

The second form occurs almost exclusively in scrofulous 
and tuberculous children, and is chiefly produced by a cheesy 
osteomyelitis. When a section is made through the bodies 
of the vertebrae, the cancellated tissue is found to be filled 
with cheesy material, in the vicinity of which small tuber- 
cles may often be plainly recognized. The bodies of the 
vertebrae are destroyed as in simple caries, and prevertebral 
abscesses are formed, which extend in the manner above de- 
scribed. A minute description of the process will be given 
in considering the bones of the extremities. 

Cartilaginous, and especially bony new formations are 
very common, particularly in the form of supracartilaginous 
exostoses, which will be hereafter described (with the bones 
of the extremities). These sometimes originate from the 
contiguous sides of two vertebrae and then become fused, 
thus forming a bridge over the intervertebral substance. 



THE PELVIC BONES. 385 

Heteroplastic growths, especially sarcoma and cancer, some- 
times occur by extending from neighboring parts, and the 
former also occur primarily. 

16. THE PELVIC BONES, 
(a.) General Characteristics. 

The most important pathological conditions of the bony 
pelvis are the deformities and the resulting alterations of 
the internal dimensions. In order to examine these thor- 
oughly the entire pelvis should be completely removed from 
the body, and freed, as thoroughly as possible, from the mus- 
cular tissue. In the majority of cases, however, it is sufficient 
to observe the general shape and to take accurate measure- 
ments of the inlet ; and in most cases it is customary to take 
no further steps. It would require too much space were all 
the deformities described, as they are fully treated of in all 
the current text-books upon obstetrics ; certain general points 
only may be now stated. The pelvis is seldom widened in 
all directions (large pelvis), though very frequently narrowed 
(contracted pelvis). It is either uniformly narrowed, or 
only in the direction of certain diameters, while the others 
are of normal or increased length ; the narrowing upon the 
two sides is either about equal (symmetrical pelvis) or it 
may be unequal (unsymmetrical pelvis). The cause of the 
deformities lies in the pelvis itself, or in pathological changes 
in the vertebral column, or hip-joints. In the latter case 
the deformity is usually unilateral (unsymmetrical pelvis) 
and results from inflammation in childhood, anchylosis, or 
dislocation (coxalgic pelvis). The spinal curvatures produce 
a compensatory displacement of the sacrum, and the pelvis 
becomes consequently distorted (kyphotic pelvis). The path- 
ological changes of the pelvis itself, which result in de- 
formity, are tumors, the rare synostosis of the sacroiliac 
synchondrosis (synostotic pelvis, usually unsymmetrical), os- 
teomalacia, and lastly, rickets, which is extremely common. 
In cases of osteomalacia the pelvis has a very characteristic 

25 



386 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

shape (heart-shaped), due to the pressure of the thigh bones 
upon the acetabula, in consequence of which the latter are 
approximated, the pubic bones become pointed, and the 
sacrum projects forwards into the pelvis. Rickets does not 
always produce the same alterations ; the most common de- 
formity consists in the sacrum being depressed and pushed 
forwards more than in the normal condition, so that the an- 
teroposterior diameter is diminished, while the transverse is 
sometimes even increased. The projection of the sacrum is 
due to the rachitic changes in the sacro-iliac synchondrosis 
and the accompanying extreme softness and mobility which 
will be more fully described hereafter. When a similar 
pressure is exercised upon the ilio- pubic synchondrosis, the 
resulting deformity may resemble that due to osteomalacia. 
Besides these alterations in the shape of the true pelvis, a 
diminution in size and flattening of the hip bones also results 
from rickets. 

(5.) Special Morbid Conditions. 

Fractures of the pelvis are produced only by great vio- 
lence, and are usually associated with great injury to very 
important organs, so that death soon results, often preceded 
by extensive gangrenous inflammation and necrosis of the 
bones. Separation of the synchondroses is sometimes ob- 
served in connection with fractures. 

The inflammatory, carious processes, when not caused by 
injury, usually proceed from the hip- joint or a psoas abscess ; 
still any and all other processes in the neighboring parts, 
which are characterized by suppuration, may by extending 
produce caries of the pelvis. Caries is thus very commonly 
found on the posterior surface of the sacrum as a result of 
decubitus (bed-sore). 

In addition to the formations of bone which results from 
processes originating in the hip- joint, small exostoses some- 
times occur, seated on the ilio-pectineal line, or symphysis 
pubis ; they project like spines into the pelvis, and may cause 
lacerations during childbirth. The other tumors which occur 



THE EXTREMITIES. 387 

here are enchondroma, osteoma, sarcoma, and carcinoma. The 
latter is said to occur as a primary growth of great softness, 
and is often infiltrated throughout all the bones, so that the 
shape of the softened pelvis may resemble that affected with 
osteomalacia. 

IV. THE EXTKEMITIES. 

In the majority of cases, when the examination of the ab- 
dominal cavity is finished, the autopsy may be considered 
completed ; but in others the extremities must still be ex- 
amined. In these parts the lymphatic glands and vessels, 
the blood-vessels, nerves, muscles, joints, and bones deserve 
special consideration. The examination, of course, is limited 
to those parts only where in certain cases pathological 
changes are known to exist, or at least are suspected. 

1. THE LYMPHATIC GLANDS. 

The lymphatic glands of the extremities usually examined 
are those which lie nearest the trunk. These include the ax- 
illary and inguinal glands, both of which are not only con- 
nected with the lymphatic vessels of the extremities, but 
with other important parts. The axillary glands receive the 
lymph-vessels of the breasts also, and the inguinal glands 
those of the generative apparatus, so that they are liable 
to become involved when disease exists in either of these 
regions. 

The results of primary acute inflammation of these glands 
are rarely met with at the autopsy, though sometimes acci- 
dentally found ; evidences of secondary inflammation in cases 
of extensive inflammatory processes in the subcutaneous and 
intermuscular connective tissue, etc., are more common. The 
glands are swollen, more or less reddened, and sometimes 
contain pus (lymphadenitis apostematosa). The surround- 
ing tissue is often inflamed and infiltrated with pus {peri- 
adenitis). The pus corpuscles are distinguished from lymph 
corpuscles by their size and several small nuclei, while only 
a single large nucleus exists in the lymph corpuscle. 



DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

Chronic inflammation is manifested either by induration, 
combined with a diminution in the size of the glands, in 
which case the reticulum is thickened and the cells of the 
gland are less numerous, or by hypertrophy, in which altera- 
tion the reticulum is also found to be thickened, but the 
meshes are still filled with cells. 

Cheesy (tuberculous ?) inflammation occurs less frequently 
in these peripheral glands than in those already described, 
and when present is most likely to be seated in the cervical 
glands. The specific syphilitic affection (indolent buboes), 
on the contrary, is very common, especially in the inguinal 
glands, which become enlarged and hard, presenting a gray 
color on section, and are filled with cells. Leucaemia and 
lymphosarcoma give rise to enlargements, which sometimes 
may be very great. Primary tumors are very rare, but 
secondary ones are more common, especially cancer. As has 
already been suggested, when the axillary glands are affected, 
the primary cancer is usually seated in the breast, while the 
inguinal glands become secondarily cancerous from the exter- 
nal genitals (cancroid of the penis or clitoris), or from the 
internal (cancer of the uterus). 

2. THE LYMPHATIC VESSELS. 

The lymphatic vessels are sometimes dilated (in central 
obstruction), owing to induration and atrophy of the glands 
(elephantiasis). They may also present inflammatory 
changes (lymphangitis), which are usually secondary to 
perilymphangitis (phlegmasia alba dolens). Portions of new 
formations are sometimes found in their interior, especially 
of those near or among the axillary glands. They may also 
contain blood when haemorrhage has taken place in the re- 
gion from which they came, and the blood is then found 
also in the lymphatic glands, at an early stage in the sinuses 
surrounding the follicles. 



THE EXTREMITIES. 389 

3. THE BLOOD-VESSELS. 
The pathological changes occurring in the blood-vessels 
have already been described in connection with the aorta and 
vena cava; it is only necessary to add, that in examining 
the vessels of the extremities the incision is always to be 
made along the course of the main branches, since it is 
important to determine exactly their relation when changes 
in the larger vessels are continued from those of the extrem- 
ities. 

4. THE NERVES. 

The most important pathological change in the peripheral 
nerves is atrophy, which may often be roughly determined 
by their small size ; when teased preparations are examined 
with the microscope, the nerve fibres are found to have dis- 
appeared, usually in consequence of fatty degeneration. 

Acute inflammatory changes have been described by 
Virchow under the term neuritis interstialis proliferans. 
They are characterized by an abundant cell proliferation 
between the nerve fibres and atrophy of the latter. Chronic 
inflammatory changes are manifested by a fibrous thickening 
of the perineurium, and frequently occur in stumps after am- 
putations (false neuroma). 

The first to be considered among the tumors are the neu- 
romata, which may be defined as enlargements occurring in 
the course of a nerve, or at its termination in an amputated 
stump ; they are usually somewhat fusiform, varying from 
the size of a pea to that of a hen's egg, and are composed of 
nerve fibres. If the tumor contains white substance it is 
termed neuroma myelinicum, if not it is designated as neu- 
roma amyelinicum. Formerly, many other tumors of a sim- 
ilar shape occurring along the course of nerves were incor- 
rectly called neuromata. Among these may be mentioned 
fibromata, myxomata, and sarcomata. The latter are occa- 
sionally developed in the course of many different nerves at 
the same time. Carcinoma is very rare. 



390 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

5. THE MUSCLES. 

(a). General Characteristics. 

In examining the muscles of the extremities their size is 
first to be noticed. All the muscles or single groups only 
may present variations in this respect, and atrophy is more 
common than hypertrophy. In general atrophy their size 
can, of course, be only approximately determined, but when 
the atrophy is circumscribed, it is possible to estimate exactly 
the diminution in size, by comparing the affected part with 
the opposite side. 

The color of muscles varies from a bright grayish-red to 
the darkest shade of red, according to the amount of blood 
contained in them (color of smoked goose-breast in typhoid 
fever and cholera) ; they become yellowish-red (fatty de- 
generation or infiltration) or brownish-red (brown atrophy), 
in consequence of changes taking place in the substance of 
the muscles ; in the vicinity of ichorous abscesses, and gen- 
erally when putrefaction is present, they assume a dirty 
grayish-green or dark green color. 

The consistency depends principally upon the degree of 
post-mortem rigidity ; it is diminished in most diseased con- 
ditions, especially in atrophy and acute inflammation, and 
the tissue is then often perfectly soft, brittle, and even pulpy. 
The consistency may be increased, on the other hand, for in- 
stance, in chronic interstitial inflammation. 

(6.) Special Morbid Conditions. 

1. Hypertrophy. True hypertrophy seldom occurs, and 
when it does, it is always confined to single groups, and is 
usually the result of excessive use. The term false hyper- 
trophy has been applied to a condition in which the belly of 
the muscles appears to be enlarged, although the actual mus- 
cle is not increased in size. The enlargement is due to an 
interstitial development of fat ( fatty infiltration), which 
may very easily be distinguished by the eye, by the wide 



THE MUSCLES OF THE EXTREMITIES. 391 

and narrow, yellowish-white lines which penetrate the mus- 
cular substance in all directions. 

2. Atrophy. One form of atrophy (atrophy due to fatty 
infiltration') essentially agrees with the previous condition, 
and is very frequently found when the muscles are no longer 
used, whether owing to affections of the joints or nerves. 
The gross appearances are similar to those above described, 
except that the muscular tissue is less strongly contrasted 
with the fat the longer the process has continued, while the 
circumference of the muscle is actually lessened. When ex- 
amined microscopically, not only are fat cells found between 
the muscular fibres, as in the first case, but the fibres them- 
selves are diminished in size, of course very irregularly ; the 
transverse strisB are very obscure, apparently broken into 
separate pieces, and the picture is thus presented of the most 
extreme degree of atrophy. 

The muscles are sometimes found under similar conditions 
to be very much diminished in size ; they are not, however, 
of a pale grayish-red, but of a light or dark brown color 
(brown atrophy). This condition is found (in teased prepar- 
ations) to be due to the presence of small, irregular, brown 
pigment granules, as is the case with the similar change in 
the heart. 

There is also & fatty atrophy (atrophy due to fatty degen- 
eration), which corresponds with that occurring in the heart, 
and is characterized by its pale-yellow color and, when 
examined microscopically (teased preparations also), by the 
absence of transverse strise and the presence of glistening fat 
granules, which are insoluble in dilute caustic alkali. It is 
usually the result of an inflammatory process, and belongs 
under the head of parenchymatous myositis. It is supposed 
to be the cause of the so-called pernicious progressive mus- 
cular atrophy. 

Simple atrophy is by far the most common form, and 
appears constantly in old age and in all cachectic diseases 
(phthisis, cancer, etc.). It depends upon a simple diminution 
in size of the contractile substance, and differs from the 



392 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

above-mentioned forms of atrophy in being more uniformly 
diffused. 

3. Haemorrhages into the muscles are moderate, small, or 
punctiform. The first form is usually traumatic in its origin, 
and the others occur in septic diseases, and especially in the 
vicinity of inflammatory processes, whether the latter are 
situated within the muscles or in the neighboring parts. 
When blood is effused, the muscular fibres are separated by 
the extravasated blood, and if the haemorrhage is extensive, 
they are so much injured as to become disintegrated, the 
resulting detritus being mixed with the blood. 

4. The inflammations may be divided into those which 
involve the muscular tissue proper, and those which involve 
the interstitial tissue. 

(#.) In the former (myositis parenchymatosa) the well- 
known results, cloudy swelling and fatty degeneration, are 
presented, evident by the disappearance of the transverse 
striae, and the pale grayish or yellowish-red color and soft 
consistency of the muscle. This form occurs as a general 
affection in many infective diseases, the changes occurring in 
typhoid fever being the most familiar. In this disease the 
adductors of the thigh are most often affected, and may con- 
tain spots of actual softening. Circumscribed (local) forms 
may occur when the muscular substance takes part in in- 
flammatory processes, for instance, in purulent interstitial 
inflammation, and especially in embolic affections (pyaemia, 
ulcerative endocarditis, etc.). 

A pathological change occurring in typhoid fever with 
true parenchymatous myositis has been described by Zenker 
as waxy (hyaline) degeneration, in which the contractile 
substance is converted into a homogeneous vitreous mass, 
the transverse striae completely disappearing. Later it be- 
comes broken up transversely into rounded fragments, which 
are held together merely by the unaltered sarcolemma. 
These masses do not present the amyloid reaction, neither 
can they be looked upon as a specific typhoid alteration, as 
they appear in other diseases also, especially in those which 



THE MUSCLES OF THE EXTREMITIES. 393 

are characterized by great muscular activity, for instance, in 
acute mania, and they may even be produced artificially. 

(5.) Interstitial inflammatory affections of the muscles 
are divided into acute and chronic. The acute are accom- 
panied by suppuration (myositis inter stitialis apostematosa), 
and they may vary greatly in extent. Very large abscesses 
occur in consequence of injury, in affections of the joints, 
bones, etc. In the latter disturbances the process, which is 
at first acute, may become chronic, and the abscess becomes 
encapsuled, owing to a fibrous induration of the surrounding 
muscles. When an abscess is of long standing its walls bear 
a greater or less number of sulphur-yellow spots, which are 
due to fatty degeneration of the cells ; when this appear- 
ance is present it may be regarded as a sure sign of the long 
duration of the abscess. The contents of abscesses which 
have originated from bones are not often composed of lauda- 
ble pus, but form an ichorous mass. So-called muscular ab- 
scesses even are not always true abscesses, namely, cavities 
with liquid, purulent contents, but consist of purulent infil- 
trations with mortification of the muscular tissue, which is 
then often found as shreds floating in the fluid. 

Small, multiple muscular abscesses, of a foul character from 
the beginning, and which do not contain laudable pus but a 
dirty, grayish-yellow, thin, greasy mass, containing myriads 
of micrococci, are very important, especially with reference to 
the general diagnosis. They always excite suspicion of the 
presence of glanders. The small abscesses from emboli, 
which are consequently associated with haemorrhage and 
occur in ulcerative endocarditis, belong in the same category. 
The infective masses which obstruct the vessels (emboli of 
micrococci) give rise to a very severe interstitial and paren- 
chymatous inflammation, the latter sometimes causing a 
pulpy disintegration of the muscular fibres before any con- 
siderable quantity of pus is formed. 

Chronic interstitial myositis, like all other chronic intersti- 
tial inflammations, results in the formation of fibrous tissue 
(myositis inter stitialis fibrosa). It is always circumscribed. 



394 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

and is either primary, for instance, after chronic rheuma- 
tism (rheumatic callosities), or traumatic injury (muscular 
scars), among which are the results of morphine injections, 
or it appears secondarily after chronic inflammatory affec- 
tions of neighboring organs, especially of the bones. It is 
easily recognized by the gray fibrous masses which are fre- 
quently scattered through the atrophied muscle in the form 
of streaks. The microscopic examination of such changes is 
best made by using teased preparations, or still better, hori- 
zontal sections. 

In exceptional cases bone is found instead of fibrous tissue 
(myositis inter stitialis ossificans). This ossifying myositis 
appears as a sanatory process in the vicinity of fractures, 
producing the parosteal callus ; it may also occur in the 
same locality, though independent of fractures, as the so- 
called parosteal exostoses, which are usually started by pro- 
cesses taking place in the bones. It is sometimes the result 
of long-continued mechanical irritation (bone growths in the 
adductor muscles of riders), and still more rarely the process 
may appear without any apparent cause scattered over the 
whole skeleton ; in the latter case the muscles are converted 
into masses of bone for a greater or less distance from their 
insertions (myositis ossifica?is multiplex progressiva). This 
condition must not be confounded with the very rare calci- 
fication of the contractile substance. 

5. New formations may result from tuberculosis and 
syphilis, both of which very rarely affect the muscles. Tu- 
berculosis never occurs in the disseminated, miliary form, 
and very rarely as cheesy nodules or subrniliary tubercles. 
The same may be said of the gummy tumors, which may be 
met with varying from the size of a hazel-nut to that of a 
walnut. Both they and the tubercles are found most fre- 
quently in the vicinity of similar pathological changes in the 
bones. Their diagnosis is made according to the rules al- 
ready given in speaking of these tumors. 

The most common tumor is the sarcoma, which appears 
either as a primary growth or (by extension from bone, for 



THE JOINTS. 395 

instance) as a secondary form, and may become larger than 
a man's head. It is usually soft and composed of round cells, 
and is very often combined with other tumors, especially with 
myxoma (myxosarcoma of the thigh, etc.). The greater num- 
ber of the muscular fibres at the periphery of the tumor be- 
come atrophied and destroyed, although the development of 
sarcomatous tissue from muscular substance has been de- 
scribed. The origin of these so-called muscular sarcomata 
is very rarely found in the muscles themselves, but they 
usually originate from the fasciae, ligaments, etc. 

Carcinoma never occurs primarily in the muscles, but 
secondary eruptions, which are in part accessory (filial nod- 
ules) and in part metastatic, are at times found ; as a rule, 
they do not attain a very large size. The muscles take no 
active part in their development, but are frequently very 
much distorted, having rounded depressions upon their sur- 
face, etc. Cancer cells are sometimes found within the sar- 
colemma, although they have probably entered from without. 
These conditions may be very well seen even in fresh teased 
preparations. 

All other tumors (fibromata, lipomata, myxomata, etc.) are 
less frequent, and easily diagnosticated. 

6. The parasites which occur in the muscles still remain 
to be considered. The most important of these are the tri- 
china?, and they have already been spoken of in connection 
with the muscles of the neck and thorax. The cysticercus 
cellulosw is also frequently found in the muscles. It always 
lies between the separated muscular fibres, surrounded by a 
fibrous capsule, and is usually of the size of a pea or bean. 
Several specimens are usually found in different parts of the 
body, although solitary individuals are sometimes observed. 
When cj^sticerci have been found in the brain, they must al- 
ways be sought for in the muscles. Echinococci are rare. 

6. THE JOINTS. 

The examination of the joints begins with that of the 
exterior, and the condition of the capsule is then to be es- 
pecially noticed. 



396 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

(a.) External Examination. 

The first point to be noticed is the degree of distention of 
the capsule, which determines at the same time the size of 
the cavity. This of course depends greatly upon the normal 
anatomical structure of the joints, since those provided with 
a loose elastic capsule (knee for instance), may undergo a 
greater amount of distention than others which have a very 
tense capsule (hip-joint, metatarsal joints, etc.). 

Partial or total obliteration of the cavity of the joints may 
occur as well as their distention ; the two articular surfaces 
are then united by the formation of fibrous or bony tissue. 
When the latter occurs the term bony anchylosis is applied; 
while the former is spoken of as fibrous anchylosis. The re- 
sulting immobility of the joint must not be confounded with 
pseudo-anchylosis, which depends upon a shrinking of the 
capsule, ligaments, fascise, etc., usually due to chronic inflam- 
mation. 

The form of the capsular ligament may become altered by 
projections (hernias) which may sometimes occur at certain 
portions of the wall. 

The color of the external surface of the capsule is of but 
little importance, as it is usually the grayish-white of com- 
mon fibrous tissue ; the consistency, on the other hand, 
varies greatly, according as the cavity of the joint is filled 
with fluid (fluctuating) or solid material (firm). 

It is very important to notice any alterations in the con- 
tinuity of the capsule. Perforation may be very often sus- 
pected when a fistulous opening is observed in the integu- 
ment, and a probe should then be carefully inserted. Periar- 
ticular abscesses may also occur, and their presence should 
likewise suggest the possibility of perforation. The cautious 
employment of the probe in these cases, is of great use. 

Traumatic lacerations of the capsule differ from the perfo- 
rations which result from ulceration. They are almost inva- 
riably caused by the protrusion of the articular head of the 
bone through a rent (dislocation), so that the external ap- 



THE JOINTS. 397 

pearance of the joint is changed in the manner described in 
detail in every work on surgery. The term partial dislocation 
is applied when the two articular surfaces are carried out of 
their normal relative position while the capsule is intact. 
Dislocation may also result from the destruction of the cap- 
sule by ulceration as well as when it has been torn by vio- 
lence, if the internal ligaments, or (in case of ball and socket 
joints, especially the hip) the cotyloid depression is de- 
stroyed. 

(6.) Internal Examination. 

When the external examination has been completed, dur- 
ing which the capsule is not to be cut into even if perfora- 
tion exists, the capsule is to be opened as freely as possible ; 
the directions for disarticulation are to be followed, and care 
must be taken to avoid injury to the surface of the joint. 
The contents are now to be examined. 

1. The Contents. 

Normal joints contain merely a few drops of synovia, 
which is a perfectly clear, viscid, yellow fluid ; in the knee- 
joint, however, about a teaspoonful is usually found. When 
the contents of the joint are pathological, either a clear, 
colorless, serous fluid is present, or this fluid is mixed with 
fibrine or pus ; the latter is often of an ichorous character, 
especially when the cavity of the joint communicates with 
the external air. 

Loose bodies (corpora libera articulorum, mures articu- 
lares) sometimes occur in joints which present no other 
gross changes. These vary from the size of a millet-grain to 
that of an almond, are of a flat oval, irregular, or faceted 
shape, usually of a whitish color, and are either of a soft, 
cartilaginous, or bony consistency. When sections or teased 
fragments are examined microscopically, these bodies are 
found to be composed of fibrous tissue, frequently containing 
fat cells, or cartilage (hyaline and fibrocartilage), or bone. 
These tissues may also occur in combination. 



398 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

2. The Internal Ligaments. 

The internal ligaments (ligamentum teres, ligament a cru- 
ciata), which exist Jn certain joints, are next to be men- 
tioned. It is necessary to cut them through, in order to 
separate the articular surfaces from each other for the pur- 
pose of thorough examination. They become involved in 
many inflammatory affections of the joints, and may conse- 
quently suppurate, become necrosed, or ruptured. 

3. The Synovial Membrane. 

The synovial membrane, as is well known, is found only 
on the capsular ligament, and does not cover the articular 
surfaces. It may be thickened, both by simple oedematous 
swelling, and by an increase of its substance. Its color is 
pale-gray, but may become bright or dark-red from inflam- 
matory distention of the blood-vessels, or from the presence 
of new-formed vessels. 

The synovial surface may be covered with pus, or more 
rarely with fibrinous false membrane ; it may be smooth, or 
transformed into a granulating surface. Hemorrhages and 
small spots from embolism (ulcerative endocarditis), are 
found within the membrane ; also gray submiliary tubercles 
(secondary forms), which are frequently recognized with dif- 
ficulty. The villi, which arise from the normal synovial 
membrane, especially near its attachment to the bones, 
become unusually prominent (forming papillary growths*) in 
all chronic, inflammatory affections of the joints, and are very 
important in connection with the origin of loose bodies. They 
are composed of a soft, vascular, fibrous tissue, rich in cells, 
and frequently contain small cartilaginous nodules, which 
may assume a bony hardness, from calcification. 

These villosities must not be confounded with arborescent 
lipomata (lipoma arborescens), which consist of the projection 
of papilliform growths of the subsynovial fat tissue into the 
cavity of the joint. These may also become separated from 
their attachment, and then form free bodies. 



THE JOINTS. 399 

Ulcerative processes also occur in the synovial membrane, 
and the latter is of course perforated when perforation of 
the capsule takes place. The perforation may proceed 
from within or from without, and it is sometimes very im- 
portant to decide this question. The extent of the ulceration 
in the different layers of the wall is the important element 
to be considered, as in the cases of perforation of the intestine ; 
if the ulceration is larger in the synovial membrane than in 
the fibrous capsule, it may be inferred that the perforation 
has taken place from within ; if on the other hand it is 
larger in the capsule, it has probably taken place from the 
opposite direction. 

4. The Articular Surfaces. 

In examining the articular surfaces the condition of the 
articular cartilage is to be noted, also the possible presence 
of any bony surface, and the appearance of the articular 
sockets. 

(a.) The articular cartilage is quite singular with respect 
to alterations in volume. At the point of greatest friction, 
namely, in the middle, atrophy takes place, while at the 
periphery the cartilage becomes hypertrophied ; and these 
two changes may take place either singly or in combination. 

Enlargement appears in the form of excrescences, which 
sometimes form a continuous projection entirely around 
the bone. Atrophy may be more or less extreme, even 
leading to complete destruction of the cartilage. If this is 
not connected with a separation of portions of the cartilage, 
it is due to chondromalacia and superficial erosioyis, or to 
chondronecrosis with separation of the necrosed portions. 
These separated portions may then be found as yellowish- 
white plates floating in the contents (pus) of the joint. Their 
cartilaginous structure and the constant fatty degeneration 
of the cartilage cells may still be plainly recognized with the 
microscope. Granulations often project from the surface of 
the bone which has been thus uncovered, and form fungous 
masses spreading over the surface and the surrounding carti- 
lage. 



400 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

Fibrillation of the intercellular substance gives rise to a 
velvety appearance of the surface, and to an apparent enlarge- 
ment of the cartilage. In fresh vertical sections, which may 
be easily made, the surface of the cartilage is seen to be com- 
posed of papillae (fibres) of varying size, and the cells are 
found to be greatly increased (formation of mother-capsules), 
but in a state of fatty degeneration. The fatty degenerated 
cells are set free by the disintegration of the intercellular sub- 
stance, and may be found floating in the fluid of the joint. 

Another pathological change which belongs under the head 
of atrophy, is the fibrous degeneration which cartilage under- 
goes in various affections, for instance, in adhesive arthritis, 
and in the cotyloid cavity after dislocation of the hip, etc., 
of long duration. 

An alteration in color accompanies all these changes of 
volume and shape. The translucent bluish-white appear- 
ance of normal cartilage becomes rather grayish-white or 
yellowish-white, both in fibrous degeneration and in necrosis. 
When the layer of cartilage is very thin, its color becomes 
modified by that of the bone beneath. In one peculiar affec- 
tion (arthritis urica), the cartilage (in other respects but little 
altered) has a perfectly white, chalky color, which is distrib- 
uted in the form of spots of varying size. Examination with 
the microscope shows that the appearance is due to a deposit 
of crystalline urate of soda in the form of very fine needles, 
both within the cells and in the intercellular substance. 

It has already been stated that the consistency of the carti- 
lage is diminished in malacia, which precedes the erosions, 
and in fibrous degeneration. In the latter condition the 
consistency as well as the appearance, resembles that of vel- 
vet. The deposition of uric acid salts produces an increased 
hardness of the cartilage, but at the same time a certain 
amount of brittleness. 

(5.) The articular ends of the bones lie exposed to a greater 
or less extent, according to the quantity of cartilage which 
has been destroyed. The condition of their surfaces permits 
a general conclusion to be drawn as to the acute or chronic 



THE JOINTS. 401 

character of the process. In chronic affections, the surface 
of the bone appears as a compact but thin layer, so that none 
of the spongy portion is to be seen, while in acute processes 
the spongy masses are quite superficial and are usually in a 
state of disintegration (caries). In the latter case it is 
usually possible to determine the condition of the bone by 
the contents of the joint (pus), as extremely small pieces 
of necrosed bone are found in suspension, and produce a sand- 
like feel. Their bony character is easily determined by the 
microscope. 

The shape of the articular ends of the bones is very much 
altered in acute and chronic affections, especially in the lat- 
ter. The alteration of shape in the former is easily under- 
stood to result from the constant superficial detachment of 
the cancellated tissue of the articular ends ; in the latter form 
the cause of the alteration of shape is by no* means so evident. 
The change may be so great that in the hip-joint, for instance, 
the head of the femur is no longer recognizable. The great- 
est changes occur in the form of the so-called friction-lines, 
which appear at those points especially where motion causes 
the greatest amount of friction of the articular surfaces. The 
upper surface of the head of the femur, for instance, frequently 
appears perfectly flat, while the curve of the lower portion is 
scarcely altered. This, however, is not always the case, for 
upon careful examination it is frequently found that the head 
of the femur has completely disappeared, and with it a por- 
tion of the neck also, so that the apparent head is situated 
close to the shaft. This newly formed head is the result 
of two diametrically opposed processes, one of which is the 
gradual attrition of the old bone, and the other the forma- 
tion of new bone at the periphery. Furthermore, in the old 
bone there is not only a constant destruction, but new bone 
is at the same time formed from the marrow (osteosclerosis)^ 
which closes the medullary spaces, and forms a compact 
narrow layer upon the surface, otherwise the spongy struc- 
ture would be laid bare as in the acute process. 

The color of the surface of the bone in chronic affections, 

26 



402 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

is that of ordinary bone ; in the acute it is sometimes red, 
especially when granulations are present, sometimes yellow- 
ish when suppuration is taking place, and again greenish, 
when the process is one of an ichorous character. The con- 
sistency of the surfaces is soft in proportion to the number of 
granulations. 

(tf.) Ball-and-socket joints require further attention from 
the changes which may take place in the socket (acetabu- 
lum). The dimensions of the latter may be increased or 
diminished. The socket may be widened by acute or chronic 
inflammatory processes, and deepened by the formation of 
bone at the periphery, or by erosion and ulceration at the 
bottom, or by both these processes combined ; the latter may 
even result in perforation. A diminution in the size of the 
socket resulting in its total obliteration, and at the same time 
accompanied by a conversion of the articular cartilage into 
fibrous tissue, occurs when the head of the bone is dislocated. 
In such cases a new socket, which is more or less perfectly 
formed and even lined with cartilage, is found near the old 
one, at the point where the head rests upon the adjoining 
bone. All of these processes occur principally in the hip- 
joint (coxitis, malum coxae senile). 

5. Special Morbid Conditions. 

Most of the affections of the joints are of an inflammatory 
character, and all the parts are more or less involved, for 
when one is affected (synovial membrane, cartilage or bone) 
the others become so very quickly. 

(a.) Inflammations are divided into the simple serous or 
fibrino-serous and the purulent form. In both the synovial 
membrane is either the first or one of the first parts affected. 
The first group is found in rheumatism, especially, and is 
characterized by a reddening and swelling of the synovial 
membrane, especially of its folds, and by a disturbance of its 
secretion. When much serous fluid is secreted, it is termed 
hydarthrus ; an excess of fibrine on the other hand character- 
izes arthritis rheumatica sicca ; if abundant so as to form a 



THE JOINTS. 403 

membrane covering the bones and cartilage, the condition is 
spoken of as a fibrinous or croupous arthritis. Besides the 
synovial membrane, the bones, periosteum, and surrounding 
connective tissue are involved, being swollen, reddened, etc. 
The cartilage remains unaffected till the later stages of the 
trouble, when chondromalacia occurs. In the fibrinous forms 
fibrous tissue may replace the layer of fibrine covering the 
cartilage, and may become united to that lying upon the op- 
posite surface, and thus lead to an obliteration of the artic- 
ular cavity {arthritis rheumatica adhwsiva). The cartilage 
also is then either found to be actually converted, or in the 
process of conversion, into connective tissue. Ossification of 
the fibrous adhesions is seldom met with. 

Chronic rheumatic inflammation may be, defined as an 
affection of the joints, which is characterized on the one 
hand by a retrograde metamorphosis of the cartilage, even 
destruction of the articular end of the bone, usually without 
any excessive secretion ; and on the other, by a growth of 
periosteum around the articular surface (peripheral bone for- 
mation), and also of the perichondrium (supracartilaginous 
exostoses, especially on the vertebral column). In the early 
stages the cartilage presents the cell proliferation already 
described ; then fibrous degeneration and softening of the in- 
tercellular substance, which gives to the surface a velvety 
appearance. Later, the articulating surface of the cartilage 
has disappeared to a greater or less extent, but the edge is 
surrounded with a projecting ruff of cartilaginous nodules, 
and the bone becomes eroded, and deformed in the manner 
already described. Finally, the synovial membrane also 
becomes involved, and papillae are formed which may con- 
tain fat, cartilage, or bone, and have suggested a resem- 
blance between the membrane and a sheep's skin (Volk- 
mann). The increase in the amount of secretion (secondary 
hydarthrus), which is sometimes met with, is to be attrib- 
uted to the affection of the synovial membrane. The villi 
may become detached in the manner already described and 
remain as free bodies in the joint ; still the detachment of 



404 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

the peripheral nodular growths and the consequent forma- 
tion of loose bony bodies occurs in this affection. The princi- 
pal seat of this process is in the hip-joint (malum coxae senile), 
where the socket may be worn away, and spontaneous dislo- 
cation with the formation of a new socket may occur. 

Certain forms of chronic arthritis are due also to syphilis, 
and are especially characterized by the fact that when an 
erosion occurs in the bone, it is covered by a thin layer of con- 
nective tissue which extends through the cartilage into the 
bone ; a sort of scar results, which resembles the syphilitic 
cicatrices in other localities, owing to its irregular notched 
shape. Adhesions between the two articular surfaces are 
also frequent in this form. 

Purulent articular inflammation may be acute or chronic. 
Acute purulent arthritis, unlike the forms already described, 
is rare, seldom occuring except in those cases where there is 
a special predisposition ; its origin is either rheumatic, oftener 
traumatic, or is due to conditions present elsewhere, metas- 
tatic, in which case, as in the rheumatic form, many joints are 
affected (the polyarthritis of certain writers). It originates 
in the synovial membrane (purulent synovitis), but very 
soon extends to the cartilage and bone. The pus in the 
joint may be laudable or not (sanious, ichorous) ; it is usu- 
ally ichorous in the metastatic form, and very often so when 
the disease is of traumatic origin, or has extended from some 
other point. Its character in these cases can usually be ex- 
plained by a communication with the air or with ichorous 
abscesses, while in the first instance it must be attributed to 
the infective nature of the material which excites the disease. 
It is very probable, though rarely demonstrated, that emboli 
may act as a cause, for they produce purulent inflammation 
in other localities in the same general processes (ulcerative 
endocarditis, pyaemia, puerperal fever, etc.) in which the 
metastatic forms of synovitis occur. 

The synovial membrane is much swollen, reddened, and 
covered with a layer of pus, appearances corresponding with 
the violence of the inflammation. With the microscope it 
is found to be completely infiltrated with granulation cells. 



THE JOINTS. 405 

Perforations, whether primary or secondary, are of very 
frequent occurrence, and often of large size ; those of secon- 
dary origin are situated at the points where the capsule is 
thinnest. Periarticular abscesses are then found outside of 
the joints and are frequently of large size. 

The cartilage always becomes involved in purulent syno- 
vitis. In recent cases it is found to be thinned, and may 
even disappear, the bone being laid bare, especially at the 
sides where it is normally thinnest, and at the points of great- 
est friction. The cause of the disappearance is usually ma- 
lacia (chondritis and ulceration of the cartilage, according to 
Rindfleisch and others), less frequently necrosis or separation 
resulting from osteomyelitis. 

When the bone becomes involved the arthritis becomes a 
caries. The superficial layers of spongy tissue assume a yel- 
low color, owing to the formation of pus among the trabec- 
ular, and the cancellated structure is necrosed (molecular ne- 
crosis of Volkmann). When the finger is passed over the 
surface little sand-like particles are felt, and the pus from the 
joint imparts the same sensation, as it frequently contains 
these particles, and little pieces of necrosed cartilage. The 
surface of the bone becomes more and more eroded, chiefly 
from friction, as may be recognized from the fact that the 
friction-lines are present, corresponding to the points of 
greatest pressure. This attrition takes place on the articu- 
lar ends, and in the sockets of the joints, for instance, in 
the acetabulum, where it may reach such a degree that 
dislocation finally occurs, owing to the enlargement of the 
cavity. 

The neighboring parts are always involved in these in- 
flammations ; osteomyelitis (even with partial necrosis), peri- 
ostitis, parostitis, etc., occur. 

Chronic purulent arthritis may be recognized externally, 
by the enormous swelling of the entire joint (the knee aiul 
tarsus are most frequently affected). When a section is made 
through the diseased portion only a firm, white fibrous tissue 
(hence tumor albus) is seen, which is produced by chronic 



406 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

inflammation of the periarticular, intermuscular, and sub- 
cutaneous fibrous tissue, and which is often traversed by nu- 
merous sinuses lined with thick masses of granulations. In 
the joint itself little or no pus may be found, but the syno- 
vial membrane is converted into a soft, thick, vascular mass 
of granulations, which frequently nearly fills the articular 
cavity. The bone presents similar changes, which, according 
to Rindfleisch, represent the primary affection. An osteopo- 
rosis results from a growth of the marrow, the bony trabecule 
become diminished in size and partly necrosed, and the whole 
bone, the tarsal bones, for instance, becomes consequently so 
softened that a probe may be passed entirely through it with 
ease ( fungous caries). The cartilage is also secondarily 
affected by malacia and necrosis, for the granulations which 
spring from the bone attack it from below, while its upper 
surface is covered with granulations which grow from the 
synovial membrane and erode it from above. In such cases 
the granulations perforate the cartilage and spread out like a 
fungus upon the surface. The cartilage also takes an inde- 
pendent part in the process, as the cartilage cells proliferate, 
the capsules become enlarged, and finally communicate with 
one another ; a system of canals thus traverses the cartilage, 
and these canals constantly increase in size, owing to the 
disappearance of the intercellular substance, until the latter 
is entirely destroyed. These changes may be examined in 
suitable fresh preparations, but it is necessary to make verti- 
cal sections near the point where a perforation exists. 

Tubercles are often found in the granulations arising from 
the bone, the synovial membrane, and the fistulae, and in 
consequence of their presence Koster, Rindfleisch, and others 
have been led to consider this affection as essentially tubercu- 
lous ; a view which is not shared in by others, Virchow, for 
instance, as the tubercles are not always present. One rare 
form of articular affection, arthritis urica, gout, still remains 
to be spoken of. The changes which take place in this affec- 
tion are due to the presence of nodules (tophi) of varying 
size, composed of brittle, white, chalk-like masses, which are 



THE BONES. 407 

seated in the membrane of the joints, in the neighboring 
parts, and may protrude externally through the perforated 
skin. These masses are composed of crystalline urate of 
soda and a very little fibrine. When the crystals are ex- 
amined with a low power they appear to be acicular, but 
the use of high powers shows that they are rhombic prisms. 
The tophi also occur in the cartilage and bone, and may 
be very easily examined in sections made from the former. 
They are situated in the cellular cavities and in the inter- 
cellular substance. The crystals appear black with trans- 
mitted, and white with reflected, light. They disappear 
upon the addition of hydrochloric acid, and after a time 
whetstone crystals of pure uric acid are formed. 

(5.) The subject of dislocations of the individual joints 
belongs to surgery, and detailed information may be found in 
the text-books on this branch. The anatomical changes, 
however, which the articular surfaces (especially the head of 
the femur and the acetabulum) undergo in long-standing dis- 
locations, may be alluded to. The head of the bone presents 
the changes already described as occurring in chronic arthri- 
tis deformans, the old socket disappears and a new one is 
formed, to which, however, the head of the femur is fre- 
quently firmly adherent. 

7. THE BONES. 

The examination of the bones has for a long time been 
confined to those cases in which some disturbance could be 
recognized from without, or was suspected from the clinical 
history. In all other cases, unless attention was called to 
the bones by appearances elsewhere, their examination has 
been omitted in order to avoid possible mutilation, and also 
from the difficulty necessarily to be encountered in display- 
ing the marrow. The frequency of different affections of 
the bones, and especially of the marrow, is therefore greatly 
underestimated. At the Pathological Institute in Berlin, for 
instance, metastatic tumors, especially cancer, disseminated 
tubercles, gummy osteomyelitis, etc., are not unfrequently 



408 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

found ; the simple reason being that in every case of exten- 
sive tumor formation, constitutional syphilis, and miliary 
tuberculosis, the osseous system is always examined. It is, of 
course, not possible to examine the whole skeleton, and the 
examination of one long bone usually suffices, at least in all 
general diseases, and also when no clinical symptom points 
elsewhere. The femur can be most conveniently removed, 
and should be sawed through longitudinally. 

The removal is best accomplished in the following manner, 
as it necessitates the least amount of mutilation. A deep 
incision, extending to the bone, is to be made in the direction 
of the large femoral vessels (which also frequently need to 
be examined), from Poupart's ligament to the middle third 
of the thigh. The ligamentum patellse is then cut through 
subcutaneously, and the knee-joint isolated by separating the 
skin from the upper part of the leg and the muscles from 
the lower part of the thigh. The capsular ligament is next 
cut through and the attachments to the femur separated 
from below upwards, till finally the capsular ligament of the 
hip-joint is stretched over the head of the bone, as is done in 
disarticulation, and the latter is enucleated. By means of a 
vise and saw the bone is usually sawed through in the direc- 
tion of its neck, and the sawdust removed from the surface 
by means of a stream of water and sponge. Whenever patho- 
logical changes are seen on the exterior of the bone the 
direction of the cut may, of course, be changed. In the case 
of small children a very fine saw must be used, and it is often 
possible to divide the articular ends, which are frequently 
the only points of interest (in rickets, syphilis), with a stout 
cartilage knife. 

In examining the centre of ossification in the lower epiphy- 
sis of the thigh of new-born children, which is very impor- 
tant in medico-legal cases, the knee is to be strongly flexed 
and the ligamentum patellae cut through transversely. The 
patella is now freed somewhat at the sides, and a series of 
thin sections are to be made through the epiphysis parallel 
to its surface. The diameter of the centre of ossification in 



THE BONES. 409 

the fully developed new-born child is from two to five milli- 
meters ; at the thirty-seventh and thirty-eighth week of 
foetal life it is from one to one and a half millimeters ; pre- 
vious to the thirty-seventh week it is entirely absent. 

The examination of the bones includes that of the bones 
in general and of the various component parts. 

1. The Bones in General. 

Variation in the number of bones frequently occurs, es- 
pecially in the form of supernumerary joints in the fingers 
and toes, or of supernumerary fingers or toes. In such cases 
the external appearance does not always indicate the condi- 
tion of the bones ; for instance, the bones of a sixth finger 
may be present without any sixth finger, or the reverse may 
be the case. 

An absence of joints is also met with, especially in mon- 
strosities, the description of which is not within the plan of 
this book. 

An increase in the size of the bones of one extremity or of 
the extremities of one side may be congenital (giant-growth) ; 
it may also be due to certain pathological processes and may 
affect many bones, as in rickets, or a single bone may be 
enlarged, from fracture, for instance. An abnormal diminu- 
tion in size is much more frequently observed than an ab- 
normal enlargement. The whole skeleton may be involved 
(rachitis), or a single extremity (after dislocation, paralysis, 
etc.), or single bones (after fracture, necrosis, affections of 
the epiphyses, etc.). Alterations in shape are very common, 
and are in part the result of curvatures following fractures 
or rickets, and in part due to circumscribed thickening or 
thinning, or both together. The " sabre-bones " (bow-legs) 
are caused by rickets ; these terms are applied to the bones 
of the lower extremities, when bowed out and flattened. 

The color of the surface of bones is usually grayish-white, 
but reddish spots are present in simple inflammation ; a 
yellowish color is found in purulent inflammation and a slaty 
green in ichorous inflammation. The surface of the various 



410 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

tumors is either white, like cartilage, gray, grayish-red, etc., 
according to their composition. 

The consistency is diminished in osteomalacia and fre- 
quently also in rachitis, and may even become as soft as that 
of wax. The different tumors vary greatly in consistency, 
some being soft (medullary), others hard (fibrous), or carti- 
laginous and bony. 

The consideration of bone in general also includes solutions 
of continuity, which sometimes appear as incomplete frac- 
tures (fracture of one side of a bone combined with angular 
deformity), especially in children, and again as ordinary 
fractures (complete solution of continuity). The subject of 
fractures belongs properly to the domain of surgery, and 
consequently it will only be mentioned here in brief, that 
different forms of displacements are distinguished when the 
ends of the fractured bone are not placed in exact contact, 
according to their normal relation. Dislocatio ad axin when 
the fragments form an angle ; ad longitudinem, when one 
fragment overrides the other ; ad peripheriam when a rota- 
tion upon the axis has taken place, so that the corresponding 
points of the periphery of the fractured surfaces do not coin- 
cide ; dislocatio ad latus when the fractured surfaces present 
a lateral displacement. Impaction is a special variety of dis- 
placement (dislocatio per implantationem) in which one frag- 
ment (neck of femur, for instance), is driven into another 
(shaft of femur). 

Spontaneous fractures are to be distinguished from the 
traumatic forms, which are always accompanied by laceration 
of the periosteum. The former are also usually produced by 
external causes, though these may be trivial, but the effect is 
due largely to the localized disturbances in the osseous tis- 
sue which have taken place, from the growth of tumors, etc. 
Very frequently large portions of the bone are then com- 
pletely destroyed, so that displacement, in the ordinary sense 
of the term, cannot be spoken of. 



THE BONES. 411 

2. The Component Parts of Bone. 

After the general characteristics have been considered, 
the component parts of bone, namely, the periosteum, osse- 
ous tissue, and marrow are to be examined. 

(a.) The Periosteum. 

1. General Appearances. 

In examining the periosteum the first thing to be deter- 
mined is its relative position. It may be separated from the 
bone in consequence of injuries, abscesses, tumors, etc., or 
may present lacerations or defects, which may also be due to 
injury, inflammation, etc. 

It is increased in thickness in acute and chronic inflamma- 
tion ; in the former by an increase of its cells and interstitial 
fluid, and in the latter by the formation of a dense fibrous 
tissue. Its normal color is grayish-white, but in acute inflam- 
mation it becomes dark-red, the tint varying according to the 
intensity of the inflammation ; in purulent inflammation the 
color is frequently yellowish, in ichorous greenish, and in 
chronic inflammation white. 

It has a soft consistency in acute inflammatory swelling, 
owing to the absorption of fluid and its richness in cells, and 
becomes very firm in the chronic forms. 

2. Special Morbid Conditions. 

(a.) The inflammations are the most frequent and the most 
important of the periosteal affections. Simple inflammation 
presents peculiar characteristics, as it may give rise to the 
formation of masses of bone (periostitis ossificans') ; this is in 
fact but an exaggeration of .the physiological purpose of the 
periosteum, which serves as the matrix for the growth of 
bone in thickness by the apposition of new layers. In very 
recent cases the periosteum appears thickened, its deeper 
layers denser, but still capable of being cut. In thin ver- 
tical sections made through the membrane several trabecules 
will be found, composed of osteoid tissue, in the midst <. f a 
tissue containing numerous round and spindle-cells. Some 



412 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

of these trabecule are perpendicularly- to the surface of the 
bone and others join them together (spongoid~). These oste- 
oid columns differ from true bone in the absence of lime salts 
and in the appearance of their corpuscles, which are rather 
plump, more rounded, and the projections are thicker. They 
then become converted into true bone by the reception of 
lime salts, and form the spongy or laminated osteophyte. 

At a later period the sponge-like character of the new 
formation disappears. It is converted into a compact bony 
mass by the formation of concentric plates of bone in the 
spaces between the trabecule of the spongoid osteophyte, 
till merely a small space (for the blood-vessel) remains. 
This mass is firmly adherent to the bone, while the spong- 
oid osteophyte is the more easily detached the younger it is. 

Finally, there is a still later stage in which a partial ab- 
sorption (osteoporosis) of the compact osseous tissue takes 
place secondarily by the formation of the true medullary 
spaces. The callus which forms in the healing of fractures 
is a peculiar variety of this ossifying periostitis. It differs 
from the preceding in the production of a great quantity of 
material, and in the fact that the newly formed mass remains 
longer in the stage of osteoid tissue. 

A third form occurs in rachitis. The soft, internal layer 
of periosteum is considerably thickened and of a dark-red 
color, owing to its very vascular condition. This soft tissue 
contains very thin and delicate osteoid columns, which fre- 
quently are not converted into true bone till the rickets has 
run its course. 

Purulent inflammation of the periosteum is characterized 
by the presence of pus between the thickened and reddened 
membrane and the bone ; the pus arises from the deepest 
layer of the periosteum, and its formation causes the detach- 
ment of the latter. When the acute stage is completed 
granulations are formed upon the inner aspect of the perios- 
teum, from the surface of which the pus is then produced. 
The important secondary changes in the bones will be con- 
sidered later. 



THE BONES. 413 

The periosteum may become perforated and the pus escape 
into the neighboring parts, an event which is very likely to 
take place when the suppuration is of an ichorous character. 

Periostitis with cheesy metamorphosis of the inflammatory 
products (periostitis caseosd) is rare, but gummy periostitis 
is more common although less frequently met with in the 
dead body. In the earlier stages the deeper portions of the 
thickened periosteum appear to be converted into a soft gelat- 
inous mass, in which numerous round cells may be recog- 
nized with the aid of the microscope ; while in the more 
superficial and denser layers fusiform and stellate cells, and 
also fibres are generally found. The innermost layers very 
quickly undergo the well-known retrograde metamorphosis 
(fatty degeneration), and then appear as a homogeneous, 
rather tough but elastic, sulphur-yellow mass, which pre- 
sents a great contrast to the reddened portion surround- 
ing it, in which an ossifying periostitis is always present. 
Vestiges (loss of bone) of this process are much more 
frequently met with than these recent forms, and will be 
more fully considered directly. 

(&.) These varieties are allied to the tumors of the perios- 
teum, the bony forms of which are first to be considered. They 
cannot be separated from inflammatory periosteal growths of 
bone, and the greater number of them are of this nature. 

These tumors are termed exostoses (more exactly external 
exostoses). They consist of the circumscribed production of 
bone in the form of a tumor, firmly attached to the bone, and 
as a rule apparently belonging rather to this than to the 
periosteum, although their development takes place from the 
latter in the same manner as the periosteal ossification, which 
has been described. The secondary formation of medullary 
spaces (exostosis spongiosa), which has been spoken of, does 
not take place in all, but some of them consist of an ex- 
tremely dense, white, osseous tissue (exostosis eburnea). These 
exostoses never attain a large size. 

The sarcomata are next in frequency to these, and all vari- 
eties occur, round-, spindle-, and giant-cell forms. The sar- 



414 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

coma which arises from the periosteum is usually hard, that 
from the marrow soft, and they both possess to a remarkable 
degree the same power to ossify that exists in the tissue from 
which they spring (osteosarcoma). Giant-cell sarcomas fre- 
quently possess a brownish-red or brownish-green color, which 
is in part due to haemorrhages and in part is an essential 
characteristic of the tumor itself. 

True enchondromata, perhaps, do not occur in the perios- 
teum, as the possibility always exists that they have sprung 
from the osseous tissue. There is a form of tumor, however, 
which arises chiefly from the periosteum, and which, although 
it does not contain hyaline cartilage, still is composed of 
that cartilaginous transitional tissue which has been termed 
osteoid tissue. These tumors have therefore been called 
osteoid tumors. They frequently contain portions composed 
of bone, and metastases of similar structure may take place 
in the internal organs (malignant osteoid of Johannes 
Miiller). 

The existence of primary carcinoma in the periosteum is 
likewise very questionable. Epithelial cancer with its famil- 
iar large epithelial plugs, may be found in the tibia, for in- 
stance, but it always originates in the skin, although it may 
be less extensive in the latter. Soft tumors, which are 
commonly called cancer, sometimes originate in the perios- 
teum, but ought, perhaps, to be considered as alveolar sar- 
coma. In most cases of cancer in bone the tumors proceed 
from the marrow. 

(b.) The Osseous Tissue. 

1. General Appearances. 

In examining the substance of the bone the part first to be 
considered is : — 

(«.) The surface, where thickenings may be found as the 
result of inflammation and tumor formation in the periosteum. 
It has already been stated, that after the acute process has 
run its course, the resulting new-formed mass appears to 
belong to the bone. If the formation of bone extends over 



THE BONES. 415 

the whole or the greater part of the surface, the term hyper- 
ostosis is applied ; if it extends over only a small portion, 
periostosis ; while, if it appears as a circumscribed tumor, it 
is then called an exostosis, as above described. 

There is also an external atrophy, concentric atrophy, 
which is not only found in normal bone, but also as a very san- 
atory process in that which is newly formed, for instance, in 
callus. Wegner has demonstrated the interesting fact that 
pathological atrophy also is caused by giant-cells, myeloplaxes, 
Kolliker's osteoclasts, and consequently the giant-cells may be 
obtained for microscopic examination by scraping the surface 
of atrophied portions. 

The color of the surface of the bone may often be of great 
diagnostic value. A whitish, chalk-like, and irregular discol- 
oration is characteristic of the smallest osteophytes ; necrosis 
of the bone is often only to be recognized by the uniform 
grayish- white color contrasted with the grayish-yellow of 
normal bone. Redness of the surface always indicates an 
abnormal formation of medullary spaces and vessels. 

(b.) In a section through the bone, especially in the inte- 
rior of the latter, hypertrophy may also be seen. It is present 
principally in the spongy portion, and consists of a diminution 
in the size of the medullary spaces, owing to a thickening of 
the cancellated structure (osteosclerosis), and may become so 
extreme that a perfectly compact bony tissue results. This 
change is of an inflammatory nature, and originates in the 
marrow (osteomyelitis ossificans, vel ostitis ossificans'), as ex- 
ternal hypertrophy arises from the periosteum. A second 
form is also recognized, and appears as an increase in the 
thickness of the bone toward the medullary canal, which 
may become completely closed (in fracture, for instance), and 
is also due to an ossification of the marrow. 

Atrophy is represented by osteoporosis, a condition in which 
the normally compact bone becomes filled with medullary 
spaces, and resembles spongy tissue ; or the normal cancel- 
lated structure of the spongy tissue becomes more delicate 
and less abundant. This condition is also the result of an 



416 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

inflammation (rarefying ostitis), and consists of a transfor- 
mation of the osseous tissue into red marrow. 

Osteomalacia also belongs under the head of atrophy, 
according to Virchow, and is to be considered as an excessive 
metamorphosis of bone into marrow, occurring in unusual 
places, and during which the intervening stage of osteoid car- 
tilage is present. Red, yellow, and gelatinous atrophy, are 
distinguished according to the character of the newly formed 
marrow, and the first of these forms is acute, occurring in 
young subjects. Microscopic preparations may be easily 
obtained from this spongy bone, by making sections or by 
breaking off spiculse of bone. The atrophied trabecule 
are very distinctly seen surrounded by a border of osteoid 
tissue, which is deeply stained with carmine, and the med- 
ullary spaces are dilated and filled with hyperasmic, even 
hemorrhagic marrow. When the color is white, or gray- 
ish-white, it is important as indicating necrosed portions. 
The consistency is diminished in osteomalacia and in ex- 
treme cases of rickets. 

2. Special Morbid Conditions. 

(a.) The most important affections of the osseous tissue 
are the purulent inflammations (caries), which have been 
mentioned in connection with the articular ends of the bones. 
The necrotic destruction of the minutest portions of bone 
(molecular necrosis) takes place in other portions, as well as 
in the ends of the bone, as the result of the extension of 
inflammation from the periosteum or marrow, and an ulcer of 
the bone results. Purulent inflammation in compact bone is 
always combined with osteoporosis, as a transformation of 
osseous tissue into marrow first takes place, after which pus 
is formed in the latter and gives rise to necrosis. The pus is 
formed at the same time in different localities which do not 
directly communicate, and is therefore infiltrated through 
the osseous tissue, and does not collect in abscesses as in fibrous 
tissue. There is a second form of purulent inflammation of 
bone which differs from the above extended variety in its 
method of origin ; it is limited to the vicinity of dead pieces 



TEE BONES. 417 

of bone (necrosis) where it produces inflammatory demarca- 
tion^ as happens in other organs, in which dead parts are 
separated from the living by a purulent inflammation around 
the former. 

Necrosis, the death of a large piece of bone, may be due to 
various causes, the most common of which is external vio- 
lence (necrosis from concussion) ; it may also be due to in- 
flammation of the neighboring parts. For instance, necrosis 
of the most superficial lamellae of bone (superficial necrosis') 
always follows the detachment of the periosteum from the 
bone by pus, and the same result occurs in the interior of the 
bone (central necrosis), when the marrow is inflamed. The 
necrosed fragment is characterized by its white color, com- 
plete deprivation of blood, and by its being more or less sep- 
arated, according to the duration of the process, from the 
surrounding parts by purulent inflammation (caries). A pe- 
culiar form of caries is produced by syphilitic processes, as 
gummata are developed in the superficial portions of the 
bone in connection with a gummous periostitis, and a depres- 
sion (scar) remains in the bone after they become disinte- 
grated. There is no formation of pus in such places, though 
a purulent ostitis may accompany the process. 

(b.) There are but few tumors developed in the osseous 
tissue. Small osseous growths of a tumor-like character are 
found in the spongy tissue (enostoses) ; but the most impor- 
tant forms are the peripheral enchondromata, the development 
of which Virchow is very much inclined to attribute to the 
inclusion of portions of cartilage which remain undeveloped 
within the bone (rickets). The osseous tissue plays a nega 
tive part in the formation of many tumors of the marrow. 

(c.) There are certain alterations of the epiphyseal carti- 
lage which occur at the line of ossification, and affect both 
cartilage and bone. The changes occurring in rachitis are 
first to be mentioned, and are evinced by an increase in the 
width of the translucent, bluish-gray zone of proliferation in 
the cartilage; also by an increase in the width and an 
irregular course of the white layer of provisional calcifica- 

27 



418 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

tion, and by an irregular extension of the medullary canals 
with their loops of vessels. "With the microscope the normal 
growth of the cartilage cells is seen to be greatly increased, 
the cells and intercellular substance are dropsical, the zone 
of calcification is very wide and provided with numerous, 
often wide projections ; the formation of bone takes place in 
a similar irregular manner, and a direct ossification of the 
cartilage is often apparent. It may be stated in general 
that those processes which normally follow one another in 
the transformation of cartilage into bone, pursue their course 
side by side in rickets. Many pieces of cartilage never ossify, 
and it is from them that enchondromata may be developed 
at a later period. 

Another very interesting and important affection of this 
zone is due to intra-uterine syphilis, and indicates hereditary 
syphilis. In this, too, there is great irregularity in the calci- 
fication, very similar to that in rickets, and a layer of soft, 
yellowish- white tissue lies between the calcified portion and 
the bone, which is considered by Wegner as inflammatory 
(hence osteochondritis'), and by Waldeyer and Kobner as 
gummous, A very great development of this tissue may 
cause a separation of the epiphyses. 

A special form of osseous tumor, the cartilaginous exostosis, 
originates in the epiphyseal cartilage. It may occur as a 
multiple growth on the same or on several bones. A long 
bony process, the point of which is covered with cartilage, 
projects from the joint. It seems as if the epiphyseal carti- 
lage retained its natural function of producing bone even in 
its pathological outgrowths. 

(c.) The Marrow. 

1. General Appearances. 

The marrow of the long bones varies greatly in quantity, 
the medullary spaces of the spongy portion, in particular, be- 
ing sometimes increased in size (osteoporosis), and sometimes 
diminished (osteosclerosis). The color is rather more im- 
portant, not only that of the marrow as a whole or of large 



THE BONES. 419 

portions of it (red, yellow, fatty, translucent, and brown), but 
also of small circumscribed portions (red, dull yellow, lemon- 
yellow, greenish, etc.). The consistency, which is ordinarily 
very soft, may become decidedly gelatinous, even quivering, 
or else more or less indurated ; the latter condition is usually 
limited to small circumscribed portions of the tissue. 

2. Special Morbid Conditions. 

The marrow undergoes considerable change in the normal 
processes of development and growth, and is liable to a large 
number of pathological changes, as has been more and more 
made evident in recent times. In young people the marrow 
of all the bones is red and very rich in round, colorless cells 
with large nuclei ; but after puberty the red color, though 
retained in the flat bones, vertebras, etc., is replaced in the 
long bones by a yellow color, fat being deposited in the cells 
and fatty tissue formed. This yellow or fatty marrow often 
becomes of a light brownish color, translucent, and of a jelly- 
like consistency (gelatinous marrow) in old age. A patho- 
logical reversion to the red variety sometimes takes place in 
the fatty marrow of adults, in consequence of inflammation or 
the development of new formations, and may involve the 
whole marrow of the bone in which the process is seated, or 
only limited portions of it ; this reversion invariably takes 
place before fatty marrow is converted into pus or a new 
formation. The fatty marrow, on the other hand, sometimes 
passes over prematurely into the gelatinous variety, as a rule 
in consequence of some cachexia, and this gelatinous atro- 
phy is generally associated with atrophy of the cancellated 
structure of the epiphyses, or osteoporosis. 

(a.) Of the different forms of inflammation to which the 
marrow is subject, the ossifying form (osteomyelitis ossificans} 
is rather reparative or protective in its nature, and often 
forms a barrier to the extension of more dangerous processes ; 
it is by this process, for instance, that the medullary cavity 
is sealed up and recovery rendered possible in fractures, am- 
putations, and disarticulations of the bones, and also by this 
process that a bony capsule is sometimes formed round 
tumors, etc. 



420 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

Purulent osteomyelitis is manifested by circumscribed yel- 
low spots from which a thin fluid can be squeezed out, and 
occurs by preference in the epiphyses, especially of young sub- 
jects. The yellow spots of suppuration are always surrounded 
by the red variety of marrow. The pus corpuscles are gen- 
erally found to be much disintegrated, and the pus is so cor- 
rosive in character that the operator must be on his guard 
against infection. Purulent osteomyelitis may give rise to 
necrosis of portions of the bone, especially in those cases in 
which the inflammation is of a putrid character {osteomy- 
elitis ichorosa) ; these cases are indicated by a more or less 
dark greenish discoloration of the marrow. 

Pus may undergo cheesy degeneration in the bones, as well 
as in other organs, of scrofulous subjects, and the cheesy 
masses are always surrounded by a red zone. Osteomyelitis 
caseosa occurs chiefly near the articular ends of the bones 
and there forms the anatomical basis of caries of the joints. 

(5.) Syphilitic osteomyelitis {osteomyelitis gummosa) bears 
a very close resemblance to the cheesy form, the yellow masses 
to which it gives rise being only rather more dense, of a 
shade more like that of sulphur, and, as elsewhere, present- 
ing under the microscope evidence of fatty degeneration. 
This affection is much more common than was formerly sup- 
posed, and leads us next to the consideration of tumors in 
this locality. 

Tubercle occurs in the marrow both as the circumscribed or 
secondary form about collections of cheesy material, and as 
the miliary, disseminated form ; in the latter, the granules are 
often very difficult of recognition from their close resem- 
blance to transverse sections of the bony trabecular ; but their 
true nature is shown by the facility with which they can be 
isolated and removed from the red marrow in which they 
are imbedded. 

Myelogenous or endosteal sarcoma is generally softer than 
periosteal sarcoma and, even after having attained the size 
of the head of an adult, may be enclosed in a thin shell of 
bony tissue (tumeurs enkystes) which cannot be regarded as 



THE BONES. 421 

the remains of the old bone, but as newly developed from the 
periosteum. These tumors may be of either the round-, spin- 
dle-, or giant-cell variety, and the soft round-cell sarcomas, in 
particular, are very vascular and often the seat of large mul- 
tiple haemorrhages (sarcoma telangiectodes, fungus hatmato- 
des). Cysts, usually multiple, may result from haemorrhages 
as well as from partial mucous degeneration. Myxoma is 
rather more rare, enchondroma more common, while primary 
carcinoma is very rare and, if indeed it occurs at all, would 
perhaps be more properly classed as alveolar sarcoma. Metas- 
tatic nodules of carcinoma, on the other hand, are very com- 
mon, multiple, and rarely exceed a bean in size. A highly 
vascular form of carcinoma is also met with which pulsates 
during life, and may be the seat of haemorrhages and their 
consequences, precisely like the similar form of sarcoma. 
The occasional occurrence of fracture, in consequence of the 
development of a soft variety of tumor, has been already 
alluded to. 

It only remains to mention a few rare changes which are 
sometimes found in the marrow in certain diseases. In re- 
lapsing fever a species of local necrobiosis occasionally takes 
place, and forms a circumscribed mass consisting of disin- 
tegrated cells and fatty degenerated capillaries. 

In many cases of leucaemia, etc., a peculiar enlargement 
or swelling of the marrow is sometimes found, which is as- 
sociated with a grayish-purple, yellowish, or even puriform, 
discoloration ; the enlargement as well as the discoloration 
depends on the presence of masses of the lymphoid, transition 
form of red blood-corpuscles (nucleated red blood-corpus- 
cles). Even when the leucaemia is not absolutely myelogen- 
ous there are invariably found large numbers of those color- 
less octahedral crystals which have already been spoken of, 
and which are usually found after death in all bone-marrow, 
though in smaller numbers. Cohnheim has called attention 
to a change which he finds in the marrow in pernicious 
anwmia, and which is very similar to that above described. 
The marrow is deeply reddened, and is said by him to con- 



422 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

tain numbers of colored corpuscles with colored nuclei, in 
addition to the large and small colorless marrow-cells and 
normal red blood-disks. 

In typhoid fever it is not uncommon to find that the red- 
dened bone-marrow contains a few nucleated red blood-disks 
and many cells containing red blood-disks. 

3. Morbid Conditions of the Bones in General. 

The changes which occur in the individual component parts 
of bone having been described, some of their chief combina- 
tions in these different parts remain for consideration. 

(a.) Fracture of bone is attended with changes in all the 
parts of which bone is composed and in the neighboring tis- 
sues, and the age of a fracture can be approximately deter- 
mined only through an acquaintance with the modifications 
which these changes undergo with the lapse of time. The 
length of time which is required for the reparative process 
depends in any given case on the extent and nature of the 
fracture, and the reaction of the bone and soft parts, etc. ; it 
is therefore impossible to lay down exact rules which will in- 
clude all cases. In general, however, in simple fracture of 
a long bone, without excessive displacement of the broken 
ends, more or less effusion of blood takes place soon after 
the injury, between the surfaces of the fracture as well as in 
the surrounding soft parts, and from the condition of this 
blood a conclusion can be drawn as to the age of the injury. 
At the beginning of the second week the blood gradually 
disappears, while the surrounding soft parts and periosteum 
become thickened and reddened, and the marrow changes 
from yellow to red at the seat of fracture. In the third 
week, while the inflammatory swelling leaves the soft parts, 
the callus (periosteal, myelogenous, par osteal) is formed from 
the periosteum, the marrow, the fractured surfaces of the 
bones, and (especially when there is considerable displace- 
ment) from the neighboring connective tissue. This callus, 
consisting at first of fibrous, and later of osteoid tissue, be- 
gins to be converted into bone from within outwards in the 



THE BONES. 423 

fourth week, and between the seventh and ninth week is 
converted into bone throughout. It is then diminished in 
size and loses its angles and roughness by concentric atro- 
phy from without, while excentric atrophy begins simultane- 
ously in the medullary cavity, which was more or less closed 
by the myelogenous callus ; the cavity in both ends of the 
fractured bone is not only thus restored, but the two cavities 
are united into one, even when one fragment overrides the 
other. This osteoporosis of the inner layers is the third 
change undergone by the callus, and compact bone is left 
only on the outside. The duration of these changes is from 
ten to twelve weeks in the simplest fractures, but may con- 
tinue for years in cases of great displacement. 

A false-joint is said to exist when the fractured ends fail 
to unite by bone, but this term should be properly limited to 
those cases in which the medullary cavities are closed by a 
myelogenous callus, the surface of which is covered with car- 
tilage, and a true articular cavity lined by connective tissue 
is consequently formed between the two fractured ends. In 
spurious false-joint the fractured ends are merely more or 
less closely united by a fibrous callus. 

(5.) Rachitis, or rickets, is a disease of early childhood (from 
six months to five years), but sometimes produces changes 
which persist up to extreme old age or death. The first 
stage has already been described, and consists in thickening 
of the articular ends of the bones (double-joints) ; the 
second consists in the deposition under the periosteum of 
soft, osteoid, but uncalcified layers ; and the third stage of 
the process consists in greatly increased absorption of the 
bone from within, consequent widening of the medullary 
canal, and unnatural redness of the marrow from vascular 
dilatation, especially in the more severe cases. The two lat- 
ter processes greatly impair the rigidity of the bones, so much 
so that bones which are thus affected bend very easily and 
can readily be cut with a knife, like the bones in osteoma- 
lacia ; this affection may, however, be distinguished from 
rickets by the fact that in it the old bones lose their lime-salts 



424 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 

and disappear, while in rickets, the new bone fails to acquire 
them. Curvature and deformity thus easily result, and may 
remain permanently after the condition which gave rise to 
them has been recovered from by a subsequent deposition of 
lime-salts, sometimes more abundantly even than is normal. 

(<?.) The various forms of inflammation are very often 
found combined in the same bone, and even in the same por- 
tion of the same bone. Nothing is more common, for in- 
stance, than a combination of purulent osteomyelitis and ossi- 
fying periostitis, which latter reaches its greatest intensity at 
that part of the surface corresponding to the seat of the former, 
but is more widely extended. Ossifying periostitis is also 
found in the neighborhood of abscesses or gummafca of the 
periosteum, and in the caries of the articular ends of bones 
which results from suppurative arthritis. The height of com- 
plication is, however, reached in necrosis, particularly when it 
involves a central portion of the bone. The bit of dead bone, 
or sequestrum, is surrounded and detached by caries of the 
bony tissue ; new bone is thrown out from the periosteum, 
sometimes over the greater part of the surface of the bone 
and in large quantities, but chiefly over the sequestrum, which 
thus becomes enclosed in a sort of capsule, in which are fis- 
tulous passages of greater or less size leading down to the 
dead bone. The surrounding soft parts are in a condition 
of chronic inflammation, and are likewise more or less rid- 
dled with fistulas, while ossifying inflammation is set up in 
the marrow ; the latter process assists in the formation of the 
capsule of the sequestrum, and may lead to closure of the 
medullary cavity. 

(<#.) A few words may be said with regard to syphilis in 
bone. As in other tissues, any or every form of inflamma- 
tion (ossifying inflammation inclusive) may be indirectly of 
syphilitic origin, though the only forms of a true specific 
nature are gummous periostitis and osteomyelitis, and these 
forms can be recognized as specific only when the gummy 
formation has not been absorbed. If absorption has taken 
place irregularly shaped depressions and defects are found 



TEE BONES. 425 

on the surface of the bone, which may be the result of other 
and entirely different affections, but always awaken the sus- 
picion of syphilis, especially when they are multiple. This 
very element of multiplicity may, indeed, excite suspicion of 
the real nature of inflammations which are apparently per- 
fectly simple, but never justifies the positive diagnosis of 
syphilis unless it is supported by other evidences. The par- 
tiality which is shown by syphilitic inflammation for the 
anterior surface of the tibia is well known and of clinical 
value ; its cause may perhaps lie in the extreme liability of 
the part to mechanical injury. 

(g.) Brief allusions must finally be made to the condition 
of the bony tissue bordering on growing tumors. Ossifying 
inflammation is very apt to be set up both in the periosteum 
and marrow, and osteoporosis is often combined with these 
processes, especially when the growth originates in* the 
marrow. These myelogenous tumors often make great de- 
mands on the periosteum, which is obliged to form new 
bone constantly in order to cover the increasing surface of 
the tumor (encysted tumors). 



INDEX. 



A. 



Abdomen, contents of, 100. 

free bodies in, 102. 

haemorrhage into, 101. 

inspection of, 96. 

method of examination, 181. 
Abscess of abdominal walls, 244, 304. 

of aorta, atheromatous, 376. 

of brain, 79. 

of heart, 126. 

of ilio-psoas muscle, 381. 

of intestine, embolic, 354. 

of intestine, follicular, 357. 

of kidney, 213. 

of kidney, surface of, 204. 

of liver, 325. 

of lungs, 145. 

of muscles, 393. 

of skin, 19. 

of spleen, 194. 

of testicle, 236. 

of uterus, 254. 

periai'ticular, 405. 

perinephritic, 201. 

prevertebral, 384. 

prostatic, 232. 

retropharyngeal, 180. 
Acetabulum, alteration of, 402. 

in dislocation of hip, 407. 
Acids, as reagents, 6. 

poisoning from, 297. 
Acne of cervix uteri, 257. 

of pancreas, 336. 

of skin, 24. 
Addison's disease, 200. 
Adenoma of kidney, 220. 

of ovarv, 269. 

of prostate, 232. 

of skin, 35. 
Alkalies as reagents, 6. 

poisoning from, 297. 
Alveolar sarcoma of bones, 421. 
Amyloid degeneration of cceliac ganglion, 
336. 

of intestine, 366. 

of kidnev, 208. 

of liver, 320. 

of lymph glands, mesenteric, 340. 



Amyloid degeneration of lymph glands, 
retroperitoneal, 380. 

of pancreas, 335. 

of spleen, 192. 

of stomach, 294. 

of supra-renal capsule, 199. 

of thyroid gland, 179. 
Anchylosis of joints, 396. 
Anencephalous foetus, 68. 
Aneurism, 377. 

of cerebral arteries, 63. 

of heart, 127. 

of valves of heart, 130. 
Angina, 166, 168. 
Anthracosis of lung, 138. 
Anus, condyloma of, 275. 

prolapse of, 274. 
Aorta, in general, 372. 

origin of, 132. 
Apoplexy, cerebral, 76. 
Appendices epiploicse, lipoma, 344. 
Appendix vermiformis, diseases of, 367. 
Arachnitis cerebralis basilaris, 62. 

cerebralis convexa, 59. 

spinalis, 43. 
Arsenic, poisoning from, 298. 
Arteries, in general, 373. 

of heart, 112. 

of lungs, 159. 

of neck, 164. 
Arteritis umbilicalis, 88. 
Arthritis, in general, 402. 

urica, 400, 406. 
Arytenoid cartilage, inflammation of, 176. 
Ascaris lumbricoides, 350. 
Atelectasis, pulmonary, 140. 
Atheroma of aorta, 376. 

of cerebral vessels, (52. 

of labia majora, 241. 

of skin, 27. 

of testis, 236. 
Atresia of aorta, 379. 

of intestine, 344. 

of rectum, 273. 

of uterus, 250. 

of vagina, 242. 
Atrophy of bone, concentric, 415. 

of coeliac ganglion. 336. 

of cranium, bones of, 49. 



428 



INDEX. 



Atrophy of heart. 122. 

of kidney, 202, 206. 

of liver, 316. 

of liver, acute yellow, 323. 

of muscles of extremities, 391. 

of nerves of extremities, 389. 

of optic nerve, gray, 86. 

of pancreas, 334. 

of spinal cord, 44. 

of spleen, 191. 

of subcutaneous fat tissue, 10. 

of subpericardial fat tissue, 111. 



B. 



Bacteria. See Schistomycetes, 
Bile-ducts. See Gall-ducts. 
Biliary calculi, 304. 

coloring matter in blood, 118. 

coloring matter in kidney, 217. 

coloring matter in liver, 319. 
Bilirubine crystals in blood, 118. 

infarction of kidney, 217. 
Bladder, diseases of, 227. 

general examination of, 223. 

removal of, 225. 

trabecular hypertrophy of, 227. 
Blood-corpuscles, white, 116. 
Blood, pathology of, 114. 

in intestine, 348. 

in lvmph-vessels, 388. 

in stomach, 283. 

vessels, disease of, 369. 
Bodies, loose in abdomen, 102. 

loose in joints, 397, 403. 

loose in tunica vaginalis, 235. 

Pacchionian, 53. 
Bone, articular end of, 400. 

diseases of, 422. 

of extremities, removal of, 408. 

general examination of, 409. 

inflammation of, 424. 

jaw, diseases of, 83. 

marrow, 418. 

new formation of in skull, 49. 

of pelvis, 385. 

syphilis, in general, 424. 

tissue, alterations of, 414. 
Bow-legs, 409. 
Brain, diseases of, 76. 

diseases of surface, 64. 

method of removal, 61. 

section of, 67, 70, 74. 
Breast. See Mammary Gland. 
Broad ligaments of uterus, affections of, 

262. 
Bronchial lvmph-glands, affections of, 

161. 
Bronchiectasis, 154. 
Bronchi, large, diseases of, 158. 

small, diseases of, 151. 
Bronchitis fibrinosa, 146. 

putrida, 154. 

tuberculosa, 153. 



Bronchocele. See Goitre. 
Bronze-skin, 10. 
Buboes, 388. 



C 



Cadaveric changes in blood, 115. 

changes in kidney, 207. 

changes in liver, 310, 312. 

changes in skin, 11. 

changes in stomach, 280, 287. 

rigidity, 12. 
Calcification of aorta, 376. 

of arteries, 377. 

of glomeruli of kidney, 203. 

of lymph-glands, bronchial, 161. 

of lymph-glands, mesenteric, 339. 

of mvoma of uterus, 261. 

of testicle, 240. 
Calculi, biliary, 304. 

pancreatic, 336. 

prostatic, 232. 

pulmonary, 157. 

urinary, 221. 225. 
Callus, forms of, 423. 

parosteal, 394. 

periostea], 412. 
Cancer. See Carcinoma. 
Cancerous phthisis, 157. 

thrombi in hepatic veins, 331 . 

thrombi in renal veins, 209. 
Cancroid, histologv of. 37. 

of skin, 36. 
Capsule of joints. 396. 

of kidnev, 201. 

of liver, 311. 

of sequestrum, 424. 

of spleen, 189. 
Capsules, supra-renal, 198. 
Carcinoma, method of examining, 35. 

of bladder, 229. 

of bone, 421. 

of brain, 80. 

of broad ligaments, 263. 

of bronchi, 159. 

of clitoris, 241. 

of duodenum, 285. 

of heart, 127. 

of intestine, 366. 

of jaw. 83. 

of kidnev. 220. 

of liver, '330. 

of lungs, 157. 

of lymph-glands, mesenteric, 339. 

of ivmph-glands, retroperitoneal, 
380. 

of mammary gland, 94. 

of muscles, 395. 

of nerves, 389. 

of oesophagus, 172. 

of omentum, 184. 

of ovary, 269. 

of pancreas, 335. 

of pelvic peritoneum, 271. 



INDEX. 



429 



Carcinoma of pelvis, 387. 

of periosteum, 414. 

of peritoneum, 183. 

of pleura, 134. 

of prostate, 232. 

of rectum, 277. 

of skin, 35. 

of stomach, mucous membrane of, 
292. 

of stomach, serous membrane of, 
281. 

of supra-renal capsules, 200. 

of testicle, 240. 

of thyroid gland, 178. 

of uterus, 258. 

of vagina, 245. 
Caries fungosa, 406- 

syphilitica, 417. 

of bone, in general, 424. 

of bone, articular ends of, 401, 405. 

of bone tissue, 416. 

of ear, 82, 87. 

of pelvis, 386. 

of petrous bone, 87. 

of ribs, 106. 

of spine, 384. 

of sternum, 105. 
Carmine, 8. 

Carnification of lungs, 146. 
Cartilage, costal, alterations from age, 
106. 

costal, alterations from rickets, 103, 
105. 

epiphyseal, 417. 

epiphyseal, centre of ossification, 
408. 

of joints, 399, 406. 

larynx, inflammation of, 176. 

ossification of, 417. 
Casts, hyaline in bladder, 224. 

hyaline in kidney, 216. 
Catarrh of bronchi. 158. 

of common bile-duct, 299. 

of intestine, 355. 

of kidney, 215. 

of lung, 146. 

of rectum, 275. 

of stomach, 288. 

of uterus, 255. 

of vagina, 243. 
Cavernoma of liver, 310, 331. 

of skin, 29. 
Cavernous fibro -myoma, 261. 
Cavities, pulmonary, 154. 
Cauliflower growth of skin, 38. 

growth of uterus, 258. 
Cephalhematoma, 47. 
Cercomonas intestinalis, 350. 
Cerebrum. See Brain. 
Cerebellum, 73. 
Cerebral sinuses, 53, 82. 
Chancre of vulva, 241. 
Cheesy degeneration of lymph-glands, 

388. 
Cheloid. See Keloid. 



Chlorosis, alterations of aorta in, 380. 

Cholelithiasis, 304. 

Cholera, contents of intestine, 347, 348. 

diphtheritic inflammation of intes- 
tine, 361. 
Cholesteatoma of brain, 81. 

of ear, 87. 
Cholesterine in atheroma of aorta, 376. 

in atheroma of skin, 27. 

in gall-stones, 305. 
Chondromalacia, 399, 403. 
Chondronecrosis, 399. 
Choroid coat, 85. 

plexus, 69. 
Chylangioma of mesentery, 337. 
Chyle, retention of in mesenteric lymph- 
vessels, 338. 
Chvle vessels of intestine tuberculous, 

342. 
Cirrhosis of liver, 326. 

of lung, 150. 
Cceliac ganglion, 336. 
Colloid cancer. See Gelatinous Cancer. 

cysts of ovary, 268. 

goitre, 178. 
Colon in typhoid fever, 364. 
Common bile-duct, 299. 
Concretions, faecal, 347. 368. 
Condyloma of mouth, 169. 

of rectum, 275. 

of skin, 25. 

of vulva, 241. 
Contents of intestine, 346. 

of stomach, 283. 

coprostasis, 347. 
Cord, spinal, diseases of, 44. 

spinal, examination of, 43. 
Corpora amylacea of brain, 78. 

amylacea of spinal cord, 45. 
Corpus luteum, 266. 
Cor villosum, 110. 
Coxalgic pelvis, 385. 
Cranium, examination of outer surface, 
46. 

examination of inner surface, 
51. 

method of opening, 49. 

sutures of, 48. 
Croup, palate and pharynx in, 167. 

larynx and trachea in, 174. 
Crystals in blood, in jaundice, 118. 

in bone-marrow, in leucsemia, 42. 

in kidney, in jaundice, 218. 

in liver, in leucsemia, 330. 

in cutis, alteration of. 17. 
Cyanotic atrophy of liver, 317. 
Cylindrical-cell cancer of breast, 95. 

cancer of intestine, 366, 
Cysticercus, structure of, 60. 

in brain, 67, SI. 

in heart, 127. 

in muscle, 395. 

in pia mater, 60. 
Cystitis. §28. 
Cystocele vaginalis, 212. 



430 



INDEX. 



Cystosarcoma of mammary gland, 96. 

of parotid, 83. 

structure of, 95. 
Cysts of bone, 420. 

of broad ligaments, 263. 

of cervix uteri, 256. 

of fibromyoma of uterus, 261. 

of intestine in chronic dysentery, 
356. 

of jaw, 83. 

of kidney, 205, 213. 

of kidney, calyx and pelvis, 222. 

of larvnx. 177. 

of liver, 331. 

of mouth, 169. 

of ovary, 268. 

of pancreas, 335. 

of skin, 27. 

of stomach, 288. 

of thyroid gland, 179. 

of trachea, 177. 



D. 



Degeneration of bone, fibrous, 378. 

of cartilage, fibrous, 400, 402. 

of muscular fibre, hyaline, 90. 

of spinal cord, descending, 45. 
Dermoid cysts of mesentery, 337. 

cysts of ovary, 270." 

cysts of skin, 27. 
Diabetes mellitus, atrophy of cceliac gan- 
glion in, 336. 

atrophy of pancreas in, 334. 

hypertrophy of liver in, 317. 
Diaphragm, position determined, 102. 

diseases of, 381. 
Diastasis of pelvic synchondroses, 386. 
Dilatation of bronchi, 154. 

of vessels of spermatic cord, 234. 
Diphtheritis, alteration of the blood in, 
120. 

in cholera, puerperal fever, faecal 
retention, variola, etc., 331. 

of bladder, 228. 

of gall-ducts, 306. 

of gall-bladder, 306. 

of intestine, dysentery, 357. 

of intestine, follicles, 359. 

of intestine, small, 360. 

of kidney, calices, 221. 

of kidney, papillae, 215. 

of larynx and trachea, 174. 

of pharynx, 167. 

of rectum, 276. 

of trachea, 174. 

of uterus, 252. 

of vagina, 244. 

of valves of heart, 130. 

of vulva, 241. 

of wounds, 22. 
Dislocation, 396, 407. 

of hip, alterations of acetabulum, 
402. 



Dislocation of hip, alteration of pelvis, 
385. 

partial, 397. 
Displacement of ends of fractured bone, 

410. 
Distoma of liver, 333. 
Diverticula of bladder, 227. 

of colon, 344. 

of oesophagus, 170. 

of small intestine, 344. 
Double-knife, method of using, 5. 

uterus, 262. 
Dropsy of joint, 402. 

of Fallopian tube, 264. 

of gall-bladder, 307. 

of ovary, follicular, 267. 

of ovary, multilocular, 269. 

of vermiform appendage, 368. 
Ductus thoracicus, 380. 
Duodenum, diseases of, 285. 

examination of, 278. 
Dura mater cerebralis, inner surface, dis- 
eases of, 55. 

cerebralis, inner surface, examina- 
tion of, 54. 

cerebralis, outer surface, diseases 
of, 52, 56. 

cerebralis, outer surface, examina- 
tion of, 50. 

spinalis, diseases of, 43. 
Dysenter} r , chronic, 356. 

diphtheritic, 357. 

follicular, 357. 

gangrenous, 358. 



E. 

Ear, 86. 

Ecchymoses, subpericardial, 111. 

Echinococcus, structure of, 81. 

of brain, 81. 

of heart, 127. 

of liver, 332. 

of lungs, 158. 

of muscle, 395. 

of omentum, 185. 

of pelvic peritoneum, 271. 

of spleen, 196. 
Eczema, 18. 
Elephantiasis of genitals, 240. 

of skin, 25. 
Emaciation, 10. 
Embolism, a cause of gangrene, 21, 377. 

fat, of lungs, 160. 

of brain, 63. 

of heart, 126. 

of intestine, 354. 

of joints, 398. 

of kidnev, 204, 213. 

of liver, 324. 

of lung, 143, 160. 

of mesenteric artery, 340. 

of skin, 17. 

of spleen, 194. 
Emphysema of lung, 137, 139. 



INDEX. 



431 



Emphysema of mediastinum, 107. 

Encephalitis, 65, 78. 

Encephalomalacia. See Softening of 

brain. 
Enchondroma of bone, 421. 

of bone, peripheral, 417. 

of parotid, 83. 

of pelvis, 387. 

of periosteum, 414. 

of testis, 239. 
Endarteritis deformans, 376. 
Endocarditis in chlorosis, 380. 

ulcerosa, 130. 
Endocardium, diseases of, 127. 
Endometritis, 252, 255. 
Enostosis, 417. 
Enteritis, 356. 
Enterocele vaginalis, 242. 
Entozoa, 127, 349. 

Ependyma of cerebral ventricles, 68. 
Epidermis, general alterations of, 16. 
Epididymitis, 236. 
Epiglottis, oedema of, 173. 

position in suffocation, 173. 
Epilepsy, injuries of the tongue in, 166. 
Epiphyseal cartilage, alterations of, 417. 
Epithelioma. See Carcinoma. 
Epulis, 83. 
Erosion of os uteri, 257. 

of stomach, 290. 
Erysipelas of intestine in diphtheritis, 358. 

of skin, 19. 
Exostosis, 413, 415. 

cartilaginous, 418. 

of pelvis, 386. 

parosteal, 394. 

supracartilaginous of spine, 384. 
Extra-uterine fcetation, 272. 
Exudation in serous cavities, 100. 
Eye, 85. 



Faecal concretions, 347, 368. 
Faeces, retention of, 347. 
Fallopian tubes, 264. 
False-joint, 423. 

passages in urethra, 231. 
Fat embolism of lungs, 160. 
Fat tissue, of capsule of kidney, 201. 

of heart, 111. 

subcutaneous, 10, 89. 
Fatty degeneration of aorta, 374. 

of glands of stomach, 289. 

of kidney, 210. 

of uterus, 255. 
Fatty heart, 123. 

liver, 318. 

marrow, 419. 

infiltration of liver, 318. 

infiltration of muscle,' 390. 

infiltration of pancreas, 334. 
Favus, 39. 
Ferment-fungus in stomach, 284. 



Fibrinous casts in urine, 216, 224. 
Fibroid of uterus. See Fibro-myoma. 
Fibroma of follicles of ovary, 267. 

of jaw, 83. 

of labia, 241. 

of mammary gland, 96. 

of mesentery, 337. 

of muscle, 395. 

of nerve, 389. 

of nose, polvpus, 84. 

of ovary, 269. 

of skin, 33. 
Fibro-myoma of prostate, 232. 

of utei-us, 259. 
Fibrous degeneration of bone, 378. 

of cartilage, 400, 402. 
Fimbriae of Fallopian tube, 264. 
Fistula of bladder, 229. 

of gall-bladder, 304. 

of intestine, 344. 

of joint, 396, 406. 

of oesophagus, 172. 

of rectum, 244, 276. 

of skin, 22. 

of testis, 237. 

of vagina, 229, 244. 
Folds of ileum, 352. 
Follicles of base of tongue, 169. 

of bladder, 228. 

of intestine, cheesy degeneration 
of, 361. 

of intestine, general enlargement 
of, 353. 

of intestine, inflammation of, 357. 

of intestine in typhoid fever, 364. 

of ovary, 266. 

of spleen, 190. 

of stomach, 292. 
Foramen ovale, open, 127. 
Fracture of bone, general characteristics, 
422. 

of bone, forms of. 410. 

of pelvis, 386. 

of spine, 384. 
Free bodies in abdomen, 102. 

in joint, 397. 403. 

in tunica vaginalis testis, 235. 
Fungus nematodes, 44. 
Furuncle, 24. 



G. 



Gall-bladder, diseases of, 303. 

examination of, 302. 

removal of, 302. 
Gall-duct, 299. 

cystic dilatation of, 331. 

tuberculosis of, 329. 
Gall-stones, 304. 
Ganglia of brain, 71. 
Ganglion, coeliac, 336. 

superior cervical, 164. 
Gangrene of extremities from embolism. 
21, 377. 



432 



INDEX. 



Gangrene of extremities from calcified 
arteries, 21, 377. 

of intestine, 358. 

of lung, circumscribed, 142. 

of lung, diffuse, 145, 147. 

of skin, 20. 

of spleen. See Malignant Pustule. 

of uterus, 252. 

of vulva, 241. 
Gangrenous phthisis, 157. 
Gastritis, 288. 
Gastroadenitis, 289. 

Gastromalacia. See Softening of Stom- 
ach. 
Gelatinous cancer of intestine, 366. 

of mammary gland, 94. 

of rectum, 277. 

of stomach. 293. 
Genital organs, female, 240. 

male, 232. 

removal of, 226. 
Germs. See Schistomycetes. 
Giant-cell sarcoma, structure of, 83. 
Giant-cells in atrophy of bone, 415. 
Glanders, abscesses in muscle, 393. 

of nose, 84. 

of skin,' 33. 
Gland, thyroid, 178. 
Glands, lymphatic, mesenteric, 337. 

lymphatic, retroperitoneal, 380. 
Glioma of brain. 80. 

of supra-renal capsules, 199. 
Glottis, oedema of, 173. 
Goitre, 178. 
Gouty joint, 406. 

kidney, 218. 
Granular atrophv of kidney, 210. 

of liver, 326. 
Granulation-tumor of kidnev, 219. 

of liver, 329. 

of skin, 30. 
Granuloma. See Granulation-tumor. 
Gumma of brain, 66. 

of epiphysis, 418. 

of heart," 127. 

of kidnev, 220. 

of liver, 328. 

of marrow, 420. 

of muscle, 394. 

of nasal mucous membrane, 84. 

of periosteum, 413. 

of salivary glands, 177. 

of supra-renal capsule, 200. 

of testis, 239. 
Gummous osteomyelitis, 420. 



H. 



Hematocele retro-uterina, 271. 
Haematoidine infarction of kidney, 217. 
Haematoma of dura mater, 55, 56". 

of peritoneum, 183. 

of rectus abdominis, 90. 

of uterus, polypoid, 254. 



Haematoma of valves of heart, 131. 

of vulva, 241. 

retro-uterine, 271. 
Hsematoxyline, preparation of, 7. 
Haemorrhage, extrameningeal, 52. 

inter- and intrameningeal, 55, 58. 

into abdomen, 101. 

into bladder, 224. 

into brain, 65, 76. 

into intestine, mucous membrane 
of, 354. 

into intestine in typhoid fever, 365. 

into kidney, calices and pelvis of, 
221. 

into kidney, parenchyma of, 207. 

into kidney, surface of, 203. 

into lung, 141. 

into mediastinum, 108. 

into mesentery, in phosphorus 
poisoning-, 337. 

into muscles of extremities, 392. 

into muscles of neck, thorax, and 
abdomen, 90. 

into pancreas, 334. 

into pericardium, 109. 

into pia mater of convexities, 58. 

into pia mater of base, 63. 

into retina, 85. 

into skin, 17. 

into skin distinguished from post- 
mortem lividity, 12. 

into stomach, 283. 

into svnovial membrane, 398. 

into testis, 236. 
Haemorrhoids of bladder, 227, 230. 

of rectum, 274. 
Heart, diseases of, 122. 

external examination of, 111. 

general changes of, 121. 

method of opening, 113, 120. 

valves of, 128. 
Hepatitis, 321. 

interstitial, 325. 

metastatic, 324. 

parenchymatous, 321. 
Hernia, intestinal. 97. 
Hip-joint, disease of, 402, 403. 
Hospital gangrene, 22. 
Horse-shoe kidnev, 198. 
Hyaline casts, 216, 224. 

degeneration of muscular fibre, 90, 
392. 
Hydarthrus. See Dropsy of Joint. 
Hvdrencephalocele, 68. 
Hydrocele, 234. 
Hydrocephalus, 68. 
Hydromeningocele, 45. 
Hydrometra, 250. 
Hydronephrosis, 222. 
Hydrops folliculorum ovarii, 267. 

multilocularis ovarii, 269. 

processus vermiformis, 368. 

tubse, 264. 

vesicas fellese, 307. 
Hydrosalpinx, 264. 



INDEX. 



433 



Hydrostatic test, 180. 
Hygroma, 28. 
Hyperostosis, 415. 
Hyperplasia of liver, 317. 

of lymphatic glands, mesenteric, 
838. 

of spleen, 191. 

of supra-renal capsule, 199. 
Hypertrophy of bladder, 227. 

of clitoris, 240. 

of heart, 125. 

of labia minora, 240. 

of liver, 317. 

of muscle, 390. 

of prostate, 231. 

of skin, 25. 

of uterus, 246, 257. 
Hypoplasia of aorta, 379. 
Hypostatic spots, 11. 



I. 



Icterus. See Jaundice. 
Ilio-psoas, 381. 

Incarceration of intestine, 343. 
Induration of lungs, brown, 139. 

of lungs, slaty, 139, 151. 
Infarction, embolic of lungs, 143. 

embolic of intestine, 354. 

haemorrhagic of lungs, 141. 

of kidney, 208. 

of kidney, papillae of, 216. 

of kidney, surface of, 204. 

of spleen, 194. 
Infective diseases, alteration of heart, 1 

alteration of kidney, 209. 

alteration of liver, 321. 

alteration of muscle, 392. 

alteration of spleen, 191. 

alteration of stomach, 289. 
Inflammation of aorta, 375. 

of bile-ducts, 424. 

of bladder, 228. 

of bone in general, 424. 

of bone-marrow, 419. 

of bone tissue, 416. 

of brain, 78. 

of choroid, 86. 

of diaphragm, 381. 

of duodenum, 285. 

of dura mater cerebralis, 53, 56. 

of ear, 87. 

of endocardium, 129. 

of epididymis, 236. 

of Fallopian tube, 264. 

of gall-bladder, exterior, 303. 

of gall-bladder, interior, 306. 

of intestine, 355. 

of joint, 402. 

of kidr. y, 209. 

of kidney, calices of, 221. 

of kidne , capsule of, 201- 

of larvn> 174. 

of liver, * 21. 

28 



Inflammation of lungs, 144. 

of lymph-glands, bronchial, 161. 

of Ivmph-glands, retroperitoneal, 
380. 

of lymph-vessels, 388. 

of lymph-vessels of pleura, 134. 

of mammary gland, 94. 

of mediastinum, 108. 

of mesentery, 337. 

of muscles of extremities, 392. 

of muscles of neck, 90. 

of myocardium, 125. 

of nerve, 389. 

of oesophagus, 171. 

of ovarv, 268. 

of palate, 166. 

of pancreas, 334. 

of parotid, 82. 

of pericardium, 109. 

of periosteum, 411. 

of peritoneum, 100, 182. 

of pharynx, 166. 

of pia mater cerebralis, 59, 64. 

of pia mater spinalis, 44. 

of pleura, 133. 

of prostate, 231. 

of retina, 85. 

of salivary gland, 177. 

of seminal vesicle, 233. 

of skin, 18. 

of spine, 384. 

of spleen, 193. 

of stomach, 288. 

of supra-renal capsule, 199. 

of testicle, 236. 

of thymus gland, 108. 

of trachea, J74. 

of tunica vaginalis, 235 

of urethra, 231. 

of uterus, 252. 

of vagina, 243. 

of veins, 370. 

of vermiform appendage, 367. 

of vulva, 241. 
Injuries of external genitals, 241. 

of oesophagus, 171. 

of skin, 13. 

of tongue in epilepsy, 166. 
Intestine, changes of position, 97. 

contents of, 346. 

diseases of, 354. 

external examination of, 340. 

method of opening, 344. 
Intussusception, 99. 
Invagination of intestine, 99. 
Inversion of uterus, 218. 



J. 



Jaundice, blood in, 118. 

catarrhal, method of determining, 

299. 
of kidnev, 217. 
of liver, "309, 319. 



434 



INDEX. 



Jaundice of spleen, 190. 
Joint, diseases of, 402. 

free bodies in, 397. 

in general, 395. 

internal ligaments of, 398. 



K. 

Keloid, 33. 

Kidney, anatomy of, 205. 

diseases of, 207. 

calices of, 220. 

examination of, 201. 

method of opening, 200. 

pelvis of, 220. 

removal of, 197. 
Kolpitis, 243. 

Koprokstasis. See Coprostasis. 
Kyphosis of spine, 382. 
Kyphotic pelvis, 385. 



L. 

Labia, 240. 

Laceration. See Rupture. 

Lac teals, tuberculosis of, 342. 

Larynx, 172. 

Lepra of pharynx, 169. 

of skin, 31. 
Leptothrix in stomach, 284. 
Leucaemia, alterations of blood, 116. 

alteration of bone, 421. 

alteration of liver, crystals, 330. 

alteration of liver, hj-pertrophy, 
329. 

alteration of liver, lvmphomata, 
329. 

alteration of lymph-glands, 388. 

alteration of lymph-glands, mes- 
enteric, 339. 

alteration of lymph-glands, retro- 
peritoneal, 380. 

alteration of spleen, 194. 
Leucine in liver, acute yellow atrophy, 
324. 

in liver, leucaemia, 330. 
Leucocytes. See "White Blood-Corpus- 
cles. 
Leucocytosis, 116. 
Lichen," 19. 
Ligament, hepato-duodenal, 299. 

of joint, internal, 398. 

of uterus, broad, 262. 
Lime-infarction of kidney, 217. 
Lipoma arborescens of synovial mem- 
brane, 398. 

of costal pleura, 162. 

of epiploic appendages, 344. 

of fat tissue, subpericardial, 111. 

of intestine, 366. 

of mammary gland, 96. 

of muscle, 395. 

of omentum, 185. 

of skin, 29. 

of stomach, 294. 



Lithopgedion, 273. 
Liver, diseases of, 316. 

examination of, general, 307. 

examination of, microscopical, 314. 

removal of, 302. 
Longitudinal sinus, thrombosis of, 54. 
Lordosis of spine, 382. 
Lung, brown induration of, 139. 

calculi of, 157. 

diseases of, 139. 

emphysema of, 137, 139. 

external examination of, 135. 

inspection of, 107. 

phthisis of, 156. 

removal of, 132. 
Lupus of pharynx, 169. 

of skin, 30. 

of skin, syphilitic, 32. 
Lymphadenitis, 387. 
Lymphangitis, 388. 

of lungs, 150, 157. 

of stomach, 280. 
Lymph-follicles of bladder, 228. 

of stomach, 292. 
Lymph-glands, axillary, 96, 387. 

bronchial, 161. 

mediastinal, 108. 

mesenteric, 337. 

of extremities, 387. 

of neck, 179. 

parametric, 263. 

portal, 307. 

retroperitoneal, 380. 

subpleural, 162. 
Lymph-vessels, 388. 

of diaphragm, 381. 

of broad ligament, 262. 

of intestine, 342. 

of pleura, 134. 

of stomach, 280. 

of testicle, 239. 

of uterus, 254. 
Lymphoma of kidney, 219. 

of liver, 329. " 

tvphoid of intestinal peritoneum, 
' 343. 
Lymphosarcoma of lymph-glands, 388. 

of spleen, 196. 

thvmicum, 108. 



M. 



Microglossia, 170. 
Malformation of aorta, 379. 

of heart, 127. 

of intestine, 344. 

of kidney, 198, 223. 

of liver, "308. 

of pancreas, 335. 

of rectum, 278. 

of skin, 40. 

of uterus, 261. 

of vagina, 242, 246. 



INDEX. 



435 



Malignant pustule, alterations of intes- 
tines, 356. 

pustule, alterations of lyinph- 
glands, mesenteric, 339. 

pustule, alterations of lymph- 
glands, retroperitoneal, 380. 

pustule, bacteridia in blood, 118. 

pustule, bacteridia in intestine, 
351. 
Mammary gland, 93. 
Marrow of bone, 418. 
Mediastinum, 107. 
Medulla oblongata, 73. 

spinalis, 43. 
Melansemia, alterations of blood, 117. 

alterations of liver, 316. 

alterations of spleen, 193. 
Melanoma, examination of, 34. 

of brain, 81. 

of clitoris, 241. 

of heart, 127. 

of liver, 331. 

of rectum, 278. 

of skin, 34. 
Membranes of brain. See Dura and Pia 
Mater. 

of spinal cord. See Dura and Pia 
Mater. 
Meningeal haemorrhage. See Haemor- 
rhage. 
Meningoencephalitis, 60, 65. 
Meningo-myelitis, 45. 
Menstruation, condition of uterus, 251. 
Mesentery, 336. 
Methvlaniline, 7. 
Metritis, 256. 

Micrococcus. See Schistomycetes. 
Milk-leg. See Phlegmasia alba dolens. 
Milk-spots of pericardium, 110. 
Molecular necrosis, 416. 

of articular ends of bone, 401. 
Mouth, 165. 
Movable kidnev, 198. 
Mulberry calculus, 221. 
Muscle, diaphragm, 381. 

microscopical examination of, 91. 

of extremities, 390. 

of neck, thorax, and abdomen, 89. 

psoas, 381. 
Mycosis irrtestinali s, 351, 356. 
Myeloplaxes. See Giant-cells. 
Myocardium, diseases of, 122. 
Myoma of heart, 127. 

of intestine, 366. 

of ovary, 269. 

of prostate, 232. 

of stomach, 294. 

of testis, 240. 

of uterus, 259. 
Myositis, 91, 392. 
Myxoidystoma of ovary, 268. 
Myxoma of bone, 421." 

of muscle, 395. 

of mammary gland, 96. 

of nerve, 389. 



Myxoma of parotid, 83. 

of skin, 39. 

of testis, 239. 

of uterus, 261. 
Myxosarcoma of thigh, 395. 



N. 



Neck, examination of, 162. 
Necrosis of bone, general alterations, 
424. 

of bone-tissue, 416. 

of intestine, 356, 358. 

of intestinal follicles in tvphoid fe- 
ver, 364. 

of mesenteric lvmph-glands in ty- 
phoid fever, 338. 

of pleura, 134. 

of vagina, 243. 
Nephritis, 209. 

catarrhalis, 215. 

urica, 218. 
Nerves of the extremities, 389. 

of the neck, 164. 
Neuritis, 389. 
Neuroma, 389. 

New-born child, external examination, 
14. 

examination of epiphyses, 408. 

test for respiration, 180. 
Noma, 21. 
Nose, 84. 
Nutmeg liver, 320. 



O. 



(Edema of genitals, 13. 

of glottis, 173. 

of lungs, 141. 

of stomach, 287. 
(Esophagus, examination of, 170. 

diseases of, 171. 
Omentum, 183. 
Oophoritis, 267. 
Optic nerve, 86. 
Orchitis, 236. 

Organization of thrombus, 370. 
Osseous tissue, 414. 
Ossification of cartilage, immediate, 417. 

of costal pleura, 102. 
Osteochondritis syphilitica, 41S. 
Osteoid tumors, 414. 

tissue in osteomalacia, 41ti. 

(issue in periostitis. 411. 
Osteoclasts in atrophy of bono, 415. 
Osteomalacia, 4 Hi. 

alteration of pelvis, 385. 
Osteoma of pelvis, 387. 

of skin, 30. 

of testis. -210. 
Osteomyelitis, 416, 419. 

caseosa oi spine, 384. 

gummosa, 420. 



-436 



INDEX. 



Osteomyelitis ossificans. 415, 419. 

with purulent arthritis, 405. 
Osteophyte, 412. 
Osteoporosis, 412, 415. 
Osteosclerosis, 415. 

of articular ends of bone, 401. 
Ostitis, 416. 

Os uteri, erosions of, 257. 
Ovary, 265. 

Ovaritis. See Oophoritis. 
Ovula Nabothi, 256. 
Oxalic acid calculus, 221. 
Oxyuris vermicularis, 350. 



Pacchionian bodies, 53, 59. 
Pachydermia lvmphangiectatica of skin, 
26. 

of os uteri, 248. 

of vagina, 242. 

of vocal cords, 175. 
Pachymeningitis cerebralis externa, 53. 

cerebralis interna, 56. 

spinalis, 43. 
Psedarthrocace, 420. 
Palate, 166. 
Pancreas, 333. 
Pancreatic calculi, 336. 
Pancreatitis, 334. 
Panniculus adiposus, 10, 89. 
Papilloma of labia, 241. 
Parametritis, 263. 
Parametrium, 262. 
Paraphlebitis, 372. 
Parasites in blood, 118. 

in brain, 67. 81. 

in heart, 127. 

in intestine, 348. 

in liver, 332. 

in lung, 158. 

in muscle, 91, 395. 

in oesophagus, 172. 

in omentum, 185. 

in skin, 38. 

in stomach, 284. 
Parietal thrombosis of aorta, 376. 

of heart, 131. 
Parostitis with purulent arthritis, 405. 
Parostosis, 394. 
Parotid gland, 82. 
Parulis, 84. 

Pelvic organs, examination of, 225. 
Pelvic peritonitis, 271. 
Pelvis, 385. 
Pemphigus, 18. 
Pentastomum of liver, 333. 
Perforation of duodenum, 285. 

of gall-bladder, o03. 

of gall-duct, 300. 

of intestine, 363. 

of intestine, differential diagnosis 
of, 344. 

of intestine in diphtheritis, 358. 



Perforation of intestine in tvphoid fever, 
365. 

of joint, capsule of, 399, 405. 

of joint, in purulent inflammation, 
404. 

of stomach, 281. 

of vermiform appendage, 368. 
Periarticular abscess, 405. 
Peribronchitis, 151. 
Pericardium, 108. 
Perichondritis arvtenoidea, 176. 

trachealis, 176. 
Pericystitis, gall-bladder, 303. 

urinarv bladder, 230. 
Perigastritis," 280. 
Perihepatitis, 311. 
Perilymphadenitis, 387. 
Perilvmphangitis, 388. 
Perimetritis, 270. 
Perinephritis, 201. 
Perioophoritis, 270. 
Periorchitis, 235. 
Periosteum, 411. 
Periostitis caseosa, 413. 

gummosa, 413. 

ossificans, 411. 

with purulent arthritis, 405. 
Periostosis, 415. 
Peripancreatitis, 334. 
Periphlebitis, in general, 372. 

of portal vein, 301. 
Periproctitis, 276. 
Perisplenitis, 189. 

Peritoneum of anterior wall of abdomen, 
182. 

of pelvis, 270. 
Peritonitis, 182. 
Peritvphlitis, 368. 
Petrifaction of lymph- glands, 161, 339. 

of mvoma of uterus, 261. 

of testis, 240. 
Pharvnx, 165. 
Phlebitis, 372. 
Phlebolites in general, 370. 

of broad ligament, 263. 

of spleen, 177. 
Phlegmasia alba dolens, 388. 
Phlegmon of broad ligament, 263. 

of gall-bladder, 306. 

of intestine, 356. 

of larvnx, 175. 

of ovarv, 268. 

of palate, 168. 

of skin, 19. 

of stomach, 289. 

of uterus, 254. 
Phosphatic calculi, 221. 
Phosphorus poisoning, 298. 

poisoning, alterations of liver, 322. 
Phthisis, cancerous, 157. 

gangrenous, 157. 
Phthisis, pulmonary, 156. 

renal is apostematosa. 214. 

renalis tuberculosa, 220. 

uterina, 257. 



INDEX. 



437 



Physometra, 250. 

Pia mater cerebralis basilaris, 62. 

cerebralis convexa, 57. 

cerebralis convexa, diseases of, 
58, 63. 

spinalis, 44. 
Pigeon-breast, 103. 
Pigment-lime calculi, 305. 

of coeliac ganglion, increased, 336. 
Pityriasis, 38. 
Placental diphtheritis, 253. 

polypus, 254. 

thrombophlebitis, 254. 
Plaques muqueuses, 32. 
Pleura costalis, 161. 

pulmonalis, 133. 
Pleural cavities, contents of, 107. 
Pneumogastric nerve. See Vagus. 
Pneumonia, 144. 

gelatinous, 141. 
Pneumothorax, opening chest, 104. 
Poisoning, cases of, method of examin- 
ing, 295. 

changes in stomach, 297. 

from acids, 297. 

from alkalies, 297. 

from arsenic, 298. 

from phosphorus, 298. 
Polypus hydatidosus uteri, 256. 

of intestine, 356, 366. 

of larynx, 177. 

of nose, 84. 

of rectum, 277. 
Pons Varolii, section of, 73. 
Porta hepatis, 307. 
Portal vein, 301. 
Pott's disease, 384. 
Pregnancy, condition of uterus, 251. 

extra-uterine, 272. 
Prevertebral abscess, 384. 
Proctitis, 275. 
Prolapsus ani, 274. 

uteri, 248. 

vaginas, 242. 
Prostate, 231. 
Prostatic calculi, 232. 
Prurigo, 19. 
Psammoma, 81. 
Pseudarthrosis, 423. 
Pseudo-leucaemia, 196. 

lymph-glands, mesenteric, 339. 

lymph-glands, retroperitoneal, 380. 
Pulmonary calculi, 157. 
Pulp of spleen, 190. 
Puncta vasculosa of brain, 65, 71. 
Putrefaction of blood, 115. 

of kidney, 207. 

of liver, "3 10, 312. 

of skin, 11. 

of stomach, 280, 287. 
Putrescent ia uteri, 252. 
Pysemic arthritis, 404. 
Pyelonephritis, 214. 
Pyometra, 250. 
Pyosalpinx, 265. 



R. 



Rachitis in general, 423. 

costal cartilages in, 103, 105. 

epiphyseal cartilages in, 417. 

pelvis in, 386. 

periostitis in, 412. 
Ranula, 170. 

pancreatica, 336. 
Reagents, 6. 

Rectocele vaginalis, 242. 
Rectum, examination of, 273. 

diseases of, 274. 

removal of, 225. 
Relapsing fever, alterations in blood, 118. 

alterations in bone, 421. 

alterations in spleen, 191. 
Respiration in new-born children, test for, 

180. 
Retina, 85. 

Retro pharyngeal abscess, 180. 
Retro-uterine hematocele, 271. 

haematoma, 271. 
Rheumatism, articular, 402. 

muscular, 394. 
Ridges on bone from attrition, 401. 
Ribs, anterior portion, 103. 

posterior portion, 161. 
Rickets. See Rachitis. 
Rigor mortis, 12. 
Rupture of bladder, 230. 

of capsule of joint, 396. 

of cerebral arteries from fatty de- 
generation, 375. 

of Fallopian tube, 265. 

of heart, 124. 

of spleen, 189. 

of uterus, 252. 

of vagina, 243. 



Sabre-bones, 409. 
Sago spleen, 192. 
Salivary glands, 177. 
Salpingitis, 264. 
Sarcina ventriculi, 284. 
Sarcocele syphilitica, 238. 
Sarcoma, examination of, 33. 

of bone-marrow, 420. 

of brain, 66, 80. 

of bronchial lymph-glands, 161. 

of heart, 127." 

of jaw, 83. 

of kidney, 220. 

of liver, '331. 

of mammary gland, 95. 

of nerve, 38*9. 

of ovary, 269. 

of parotid, 83. 

of pelvis, 387. 

of periosteum, 413. 

of prostate, 232. 

of skin, 33. 



438 



INDEX. 



Sarcoma of spine, 385. 

of stomach, 294. 

of supra-renal capsule, 200. 

of testis, 239. 

of thyroid gland, 178. 

of uterus, 261. 
Schistomycetes, in abscesses in muscle, 
393 

in blood, 118. 

in contents of intestine, 351. 

in diphtheritis of pharynx, 167. 

in embolism of thyroid, 86. 

in embolism of kidney, 213. 

in embolism of liver, 324. 

in embolism of lungs, 150. 

in kidney, pyelo-nephritis, 214. 

in skin, 19. 

in spleen, 194. 

in thrombi, 371. 

in valves of heart in malignant en- 
docarditis, 130. x . 
Scirrhus of gall-bladder, 307. 

of intestine, 366. 

of liver, 331. 

of mammary gland, 94. 

of peritoneum, 307. 

of stomach, 292. 
Sclerema neonatorum, 26. 
Scleroderma, 26. 
Sclerosis of aorta, 375. 

of bone, 415. 

of brain, 79. 

of spinal cord, 44. 
Scoliosis, 382. 
Scrofulous alterations of intestine, 361. 

alterations of lungs, 148. 

alterations of mesenteric lymph- 
glands, 339. 
Secretion from stomach, 286. 
Seminal vesicles, 232. 
Septic diseases, alterations of blood, 120. 
Sequestrum, 424. 
Serous coat of gall-bladder, 303. 

of intestine, 341. 

of liver, 311. 

of stomach, 280. 

of uterus, 270. 
Sinus-like metamorphosis of thrombus, 

370. 
Sinus, longitudinal, 53. 

transverse, 82. 
Skin, color in general, 10. 

color of different portions, 13. 

diseases of, 16. 

inflammation of, 18. 

oedema of, 13. 
Skull. See Cranium. 
Slaty discoloration of intestine, 353. 

induration of lung, 139, 151. 
Slough from intestine, in typhoid fever, 

364. 
Small-pox, 18. 

diphtheritis of intestine. 361. 
Softening of brain, 76. 

of cartilage, 399. 



Softening of stomach, 288. 
Spermatic cord, 234. 
Spermatocele, 235. 
Spina bifida, 42. 
Spinal cord, diseases of, 44. 

removal of, 41. 
Spine, from before, 382. 

from behind, 41. 
Spinous pelvis, 244, 386. 
Spleen, 186. 

gangrene of. See Malignant Pus- 
tule. 
Splenization of lung, 140. 
Spondylarthrocace, 384. 
Spongoid tissue in periostitis, 412. 
Stenosis of intestine, 344. 

of pharynx, 166. 

of rectum, 278. 
• of vagina, 242. 

of sternum, 103, 105. 
Stomach, contents of, 283. 

diseases of, 288. 

examination of, 282. 

post-mortem softening of, 281, 287. 
Stricture of urethra, 230. 
Struma, of supra-renal capsule, 199. 

of thyroid body, 178. 
Sub-maxillary gland, 177. 
Supra-renal capsule, 197, 198. 
Supplementary spleen, 186, 335. 
Sycosis parasitica, 39. 
Svnchondrosis, pelvic, separation of, 386. 
Synovia, 397. 
Synovial membrane, 398. 
Synovitis, 404. 
Sympathetic ganglion, cervical, 164. 

ganglion, cceliac, 336. 
S} r philitic affections of bone in general, 
418, 424. 

of brain, 66. 

of dura mater, 53, 56 

of epiphyseal cartilage, 418. 

of heart, 127. 

of joint, 404. 

of kidney, 212, 220. 

of larynx, 175. 

of liver, 328. 

of lung, 151. 

of lymph-glands, 388. 

of lvmph-glands. retroperitoneal, 
380. 

of muscle, 394. 

of nose, 84. 

of pancreas, 335. 

of pharynx, 169. 

of rectum, 275. 

of skin, 32. 

of spleen, 195. 

of supra-renal capsule, 200. 

of testicle, 238. 

of thymus gland. 108. 

of tunica vaginalis testis, 235. 

of vagina, 244. 

of vulva, 241. 

caries, 417. 



INDEX. 



439 



Tabes dorsalis, 44. 

mesenterica, 339. 
Taenia, 349. 

Telangiectasis of skin, 29. 
Teratoma of ovary, 270. 
Testicle, diseases of, 236. 

examination of, 235. 

removal of, 226. 

tumors of, 239. 
Thoracic duct, 380. 
Thorax, inspection of, 103. 

method of opening, 87, 104. 
Thrombosis, cancerous of hepatic vein, 
331. 

cancerous of renal vein, 209. 

in general, 369. 

of hsemorrhoidal plexus, 275. 

of mesenteric vessels, 340. 

of portal vein, 301. 

of renal vein, 209. 

of uterine plexus, 263. 

parietal of aorta, 376. 

parietal of heart, 131. 
Thrombophlebitis in general, 371. 

of broad ligament, 262. 

of portal vein, 301. 

placental, 254. 

umbilical, 88. 

uterine, 254. 

with perityphlitis, 368. 
Thrush in oesophagus, 172. 

in pharynx, 170. 

recognition of, 172. 
Thymus gland, 108. 
Thvroid gland, 178. 
Tongue, 166. 
Tonsil, 166. 
Tophi, 406. 
Trachea, 172. 

Transposition of viscera, 99. 
Trichinae, examination of, 92. 

in intestine, 348. 

in muscle, 92. 
Trichocephalus in intestine, 350. 
Tubercle in bone-marrow, 420. 

in brain, surface of, 66. 

in choroid membrane, 85. 

in heart, 127. 

in joint, caries of, 406. 

in joint, synovial membrane, 398. 

in kidney, surface of, 204. 

in pericardium, 110. 

in pleura, costal, 162. 

in pleura, pulmonary, 133. 
Tuberculosis of bladder, 228. 

of bronchi, large, 158. 

of bronchi, small, 153. 

of dura mater, 53, 57. 

of epididymis, 237. 

of Fallopian tube, 264. 

of intestine, 361. 

of intestine, surface of, 342. 

of kidney, 219. 



Tuberculosis of kidney, calices of, 221. 

of larvnx, 176. 

of liver, 328. 

of lung, 152. 

of lymph glands, bronchial, 161. 

of lymph-glands, mesenteric, 338. 

of lvmph-glands, retroperitoneal, 
380. 

of muscle, 394. 

of peritoneum, 183. 

of peritoneum, pelvic, 271. 

of pharynx, 169. 

of prostate, 232. 

of seminal vesicles, 233. 

of stomach, mucous membrane of, 
291. 

of stomach, serous membrane of, 
280. 

of spleen, 195. 

of supra-renal capsules, 199. 

of testicle, 237. 

of tongue, 169. 

of trachea, 176. 

of uterus, 257. 
Tumor albus, 405. 
Tumors of bladder, 229. 

of bone, in general, 425. 

of bone-marrow, 420. 

of bone tissue, 417. 

of brain, 80. 

of bronchi, 159. 

of duodenum, 285. 

of dura mater, 57. 

of gall-bladder, 306. 

of gall-duet, common, 301. 

of heart, 127. 

of intestine, mucous membrane of, 
366. 

of jaw, 83. 

of kidney, 229. 

of kidney, surface of, 204. 

of larvnx, 177. 

of liver, 328. 

of lung, 157. 

of lymph-glands, bronchial, 161. 

of lymph-glands, mesenteric, 339. 

of lymph-glands, retroperitoneal, 
380. 

of mammary gland, 94. 

of mouth, 1'69. 

of muscle, 394. 

of nerve, 389. 

of oesophagus, 171. 

of ovary, 268. 

of pancreas, 335. 

of parotid, 83. 

of pelvis, 386. 

of pericardium, 1 10. 

of periosteum, 413, 

of peritoneum, 183. 

of pharynx, 16!). 

of pleura, 162. 

of prostate. 232. 

of psoas, 382. 

of rectum, 277. 



440 



INDEX. 



Tumors of skin, 27. 

of spine, 384. 

of spleen, 196. 

of stomach, mucous membrane of, 
291. 

of supra-renal capsule, 199. 

of testicle, 239. 

of thyroid gland, 178. 

of trachea, 177. 

of uterus, 257. 

of vagina, 275. 

portions of in blood, 117. 

portions of in blood-vessels, 209, 
331. 

portions of in lymph vessels, 157, 
388. 
Tunica vaginalis testis, 234. 
Tvphoid fever, changes in bone-marrow, 
422. 

changes in intestine, small, 363. 

changes in intestine, surface of, 
lymphoma, 343. 

changes in larynx, 176. 

changes in liver, 329. 

changes in lymph-glands, mesen- 
teric, 337. 

changes in muscle, 392. 

changes in spleen, 191. 

changes in vermiform appendage, 
368. 

haemorrhage into intestine, 365. 
Tyrosine in liver, in acute yellow atro- 
phy, 324. 

leucaemia, 330. 



U. 



Ulcer of aorta, atheromatous, 376. 

of bile-duct, 300. 

of bone, 416. 

of intestine, annular, 362. 

of intestine, diphtheritic, 358. 

of intestine, embolic, 355. 

of intestine, follicular, 357. 

of intestine, tuberculous, 362. 

of intestine, typhoid, 364. 

of larynx, 175. 

of os uteri, rodent, 259. 

of skin, 22. 

of skin, rodent, 36. 

of stomach, 291. 

of synovial membrane. 399. 
Ulceration of intestine from without, 

343. 
Umbilicus, inflammation of vessels, 88. 
Urate infarction of kidney, 217. 
Urate of soda in joint in gout, 407. 

of soda in kidnev in gout, 218. 
Urethra, 230. 
Urinary calculi, 221, 225. 
Urine, casts in, 224. 



Uterus, 247. 

puerperal affections of, 251. 

V. 

Vagina, 241. 
Vagus nerve, 165. 
Valves of heart, 128. 
Varix of extremities, 372. 

of intestine, 355. 
Varicocele, 234. 
Variola. See Small-pox. 
Vascular tumor of liver, 331. 

tumor of skin, 29. 
Veins, calculi in, 197, 263, 370. 

diseases of, 369. 
Ventricle of brain, 67. 

of brain, diseases of, 68. 

fourth, 72. 
Vermiform appendage, 367. 
Version of uterus, 247. 
Vesiculse seminales, 232. 
Vessels of bladder, dilated, 227. 

of brain, 62. 

of liver, recognition of, 311. 

of lung, 159. 

of urethra, dilated, 230. 

of neck, 164. 

of spermatic cord, 234. 

of spleen, 197. 
Villosities of synovial membrane, 398, 403. 
Villous cancer of bladder, 229. 

cancer of gall-bladder, 306. 

heart, 110. 
Vocal cords, 175. 
Volvulus, 98. 
Vulva, 240. 



W. 

Warts, 25. 

Wandering kidney, 198. 

spleen, 186. 
Waxy degeneration. See Amyloid De- 
generation, 
degeneration of muscular fibre, 90, 
392. 
White blood-corpuscles, recognition of, 

116. 
White-swelling of joint. See Tumor 

Albus. 
Worms, 349. 

Wounds, diphtheritis of, 22. 
of oesophagus, 171. 
of skin, 13. 
See also Rupture. 



Yellow atrophy of liver, 323. 



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